Provider Demographics
NPI:1154087138
Name:EIDEL, DENA MARIE (OTR/L)
Entity Type:Individual
Prefix:
First Name:DENA
Middle Name:MARIE
Last Name:EIDEL
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 1:2165 STATE ROUTE 26
Mailing Address - Street 2:
Mailing Address - City:ENDICOTT
Mailing Address - State:NY
Mailing Address - Zip Code:13760-6412
Mailing Address - Country:US
Mailing Address - Phone:607-205-0300
Mailing Address - Fax:
Practice Address - Street 1:85 BLOOMINGROVE DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-8433
Practice Address - Country:US
Practice Address - Phone:518-283-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-13
Last Update Date:2021-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026193225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist