Provider Demographics
NPI:1578309944
Name:FEDEROW, PHOEBE GRACE
Entity type:Individual
Prefix:
First Name:PHOEBE
Middle Name:GRACE
Last Name:FEDEROW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PHOEBE
Other - Middle Name:GRACE
Other - Last Name:MOLANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:96 NORWOOD AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14222-2141
Mailing Address - Country:US
Mailing Address - Phone:631-603-4074
Mailing Address - Fax:
Practice Address - Street 1:3767 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-1040
Practice Address - Country:US
Practice Address - Phone:716-874-6175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-05
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics