Provider Demographics
NPI:1164173381
Name:WIEDEMANN, CORTNEY LYNN (COTA/L)
Entity Type:Individual
Prefix:
First Name:CORTNEY
Middle Name:LYNN
Last Name:WIEDEMANN
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 1:13000 HAWKS HILL RD
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:NY
Mailing Address - Zip Code:14080-9769
Mailing Address - Country:US
Mailing Address - Phone:716-249-7193
Mailing Address - Fax:
Practice Address - Street 1:1626 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760-1935
Practice Address - Country:US
Practice Address - Phone:716-372-0594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010939-01224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant