Provider Demographics
NPI:1922689058
Name:DIMATTEO, AUDREY ROSE
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:ROSE
Last Name:DIMATTEO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2393 BLACKHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:NY
Mailing Address - Zip Code:14569-9589
Mailing Address - Country:US
Mailing Address - Phone:585-322-0502
Mailing Address - Fax:
Practice Address - Street 1:324 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DUNKIRK
Practice Address - State:NY
Practice Address - Zip Code:14048-2145
Practice Address - Country:US
Practice Address - Phone:716-366-3631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025556-01225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics