Provider Demographics
NPI:1003071465
Name:DZIADASZEK, MARY JOAN (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JOAN
Last Name:DZIADASZEK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 BRIGGS DR
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-3127
Mailing Address - Country:US
Mailing Address - Phone:716-662-2318
Mailing Address - Fax:
Practice Address - Street 1:19 BRIGGS DR
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-3127
Practice Address - Country:US
Practice Address - Phone:716-662-2318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-25
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003349-1171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor