Provider Demographics
NPI:1275684078
Name:WIDRICK, DEAN (MS, OTR/L)
Entity Type:Individual
Prefix:MR
First Name:DEAN
Middle Name:
Last Name:WIDRICK
Suffix:
Gender:M
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 CANTERSTONE CT
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-2251
Mailing Address - Country:US
Mailing Address - Phone:919-815-4389
Mailing Address - Fax:
Practice Address - Street 1:105 CANTERSTONE CT
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-2251
Practice Address - Country:US
Practice Address - Phone:919-815-4389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4143225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC154V6OtherBLUECROSS BLUESHIELD OF NORTH CAROLINA
NC7302150Medicaid