Provider Demographics
NPI:1164070025
Name:DIETZ, ASHLEY (COTA/L)
Entity Type:Individual
Prefix:MS
First Name:ASHLEY
Middle Name:
Last Name:DIETZ
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 WEYAND AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14210-2371
Mailing Address - Country:US
Mailing Address - Phone:716-308-2205
Mailing Address - Fax:
Practice Address - Street 1:2451 BASELINE RD
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NY
Practice Address - Zip Code:14072-1657
Practice Address - Country:US
Practice Address - Phone:716-773-8870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010203-01224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant