Healthcare Provider Details

I. General information

NPI: 1326883695
Provider Name (Legal Business Name): THOMAS EDISON COMERFORD III MASTERS OF SCIENCE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2024
Last Update Date: 06/28/2024
Certification Date: 06/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 ASHLAND AVE
BUFFALO NY
14222-1307
US

IV. Provider business mailing address

512 ASHLAND AVE
BUFFALO NY
14222-1307
US

V. Phone/Fax

Practice location:
  • Phone: 607-349-8600
  • Fax:
Mailing address:
  • Phone: 607-349-8600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number646192951
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: