Healthcare Provider Details

I. General information

NPI: 1891815874
Provider Name (Legal Business Name): NICOLE SEVERYNA URDANG M.S., NCC, DHM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 LAFAYETTE AVE
BUFFALO NY
14222-1436
US

IV. Provider business mailing address

650 LAFAYETTE AVE
BUFFALO NY
14222-1436
US

V. Phone/Fax

Practice location:
  • Phone: 716-882-0848
  • Fax:
Mailing address:
  • Phone: 716-882-0848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number002563
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: