Basic Information
| Provider Information | |||||||||
| NPI: | 1477575629 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAREWELL | ||||||||
| FirstName: | MARTHA | ||||||||
| MiddleName: | J | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1773 EGGERT RD | ||||||||
| Address2: | |||||||||
| City: | AMHERST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142262352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168329626 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7 COMMUNITY DR | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142252523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7165055634 | ||||||||
| FaxNumber: | 7168921936 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 7047-1 | NY | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 00025214901 | 01 | NY | UNIVERA | OTHER | 9390329 | 01 | NY | INDEPENDENT HEALTH | OTHER |