Provider Demographics
NPI:1033687264
Name:DEWILDE, ALIZA MARIE (OTRL)
Entity Type:Individual
Prefix:
First Name:ALIZA
Middle Name:MARIE
Last Name:DEWILDE
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NY
Mailing Address - Zip Code:14513-1068
Mailing Address - Country:US
Mailing Address - Phone:315-332-2722
Mailing Address - Fax:
Practice Address - Street 1:100 SUNSET DR
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-1068
Practice Address - Country:US
Practice Address - Phone:315-332-2722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019920225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist