Provider Demographics
NPI:1275531675
Name:WOOLDRIDGE, DIANE J (PT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:J
Last Name:WOOLDRIDGE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 MAMARONECK AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10605-5224
Mailing Address - Country:US
Mailing Address - Phone:914-294-4050
Mailing Address - Fax:315-853-7629
Practice Address - Street 1:439 CHANNEL RD STE 102
Practice Address - Street 2:
Practice Address - City:LAKE WYLIE
Practice Address - State:SC
Practice Address - Zip Code:29710-6101
Practice Address - Country:US
Practice Address - Phone:803-746-7800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009744-1225100000X
SC11156225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10060832OtherCDPHP
NY02302078Medicaid
NY435741OtherMVP
NY000000070292OtherGHI
NY4902519-002OtherCIGNA
NY7330485OtherAETNA
NYAA1465Medicare ID - Type UnspecifiedGROUP
NY000000070292OtherGHI