Basic Information
Provider Information | |||||||||
NPI: | 1669539847 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | D'AGOSTINO | ||||||||
FirstName: | DAWN | ||||||||
MiddleName: | R. | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.A., CCC-A | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 272 STILL MEADOW DR | ||||||||
Address2: |   | ||||||||
City: | MACEDON | ||||||||
State: | NY | ||||||||
PostalCode: | 145029363 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5853887496 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2365 S CLINTON AVE | ||||||||
Address2: |   | ||||||||
City: | ROCHESTER | ||||||||
State: | NY | ||||||||
PostalCode: | 146182663 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5857585700 | ||||||||
FaxNumber: | 5857581297 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/03/2007 | ||||||||
LastUpdateDate: | 11/17/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 001028-1 | NY | Y |   | Speech, Language and Hearing Service Providers | Audiologist |   |
ID Information
ID | Type | State | Issuer | Description | 160743209 | 05 | NY |   | MEDICAID |