Provider Demographics
NPI:1194178624
Name:WIEDER, DINA (OTR/L)
Entity Type:Individual
Prefix:
First Name:DINA
Middle Name:
Last Name:WIEDER
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 1:35 EMPIRE LN BSMT
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5163
Mailing Address - Country:US
Mailing Address - Phone:732-998-3145
Mailing Address - Fax:
Practice Address - Street 1:35 EMPIRE LN BSMT
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5163
Practice Address - Country:US
Practice Address - Phone:732-998-3145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020468-1225X00000X
NJ46TR00733600225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist