Healthcare Provider Details

I. General information

NPI: 1417681586
Provider Name (Legal Business Name): STEPHEN FORMANOWICZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2022
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 DEAN ST
BROOKLYN NY
11217-2213
US

IV. Provider business mailing address

415 E MAIN ST
FREDONIA NY
14063-1451
US

V. Phone/Fax

Practice location:
  • Phone: 718-694-6700
  • Fax:
Mailing address:
  • Phone: 716-338-3744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number029336-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: