Provider Demographics
NPI:1164887428
Name:WIEDMER, DEBRA ANN (OT/L)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:ANN
Last Name:WIEDMER
Suffix:
Gender:F
Credentials:OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7020 STATE RT. 12
Mailing Address - Street 2:
Mailing Address - City:LOWVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13367
Mailing Address - Country:US
Mailing Address - Phone:315-376-1700
Mailing Address - Fax:315-376-6164
Practice Address - Street 1:7020 STATE RT. 12
Practice Address - Street 2:
Practice Address - City:LOWVILLE
Practice Address - State:NY
Practice Address - Zip Code:13367
Practice Address - Country:US
Practice Address - Phone:315-376-1700
Practice Address - Fax:315-376-6164
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-30
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008201-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist