Organization
CHILDPRO OF WESTERN NEW YORK
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. MARY MAI IWANENKO OTR (CEO)
(716) 822-4781
Entity
Organization
Contact information
Practice address
1025 RIDGE RD, LACKAWANNA, NY 14218-1755
(716) 822-4781
(716) 825-5765
Mailing address
1025 RIDGE RD, LACKAWANNA, NY 14218-1755
(716) 822-4781
(716) 825-5765
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
00589-1
NY
174400000X
Specialist
006796-1
NY
174400000X
Specialist
009342-1
NY
174400000X
Specialist
012804-1
NY
174400000X
Specialist
013462-1
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0224468
—
NY
Enumeration date
05/22/2007
Last updated
08/22/2020
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