Provider Demographics
NPI:1386019768
Name:DZIEDZIC, BARBARA (COTA)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:
Last Name:DZIEDZIC
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 2ND AVE E
Mailing Address - Street 2:
Mailing Address - City:FONDA
Mailing Address - State:NY
Mailing Address - Zip Code:12068-5024
Mailing Address - Country:US
Mailing Address - Phone:518-829-5266
Mailing Address - Fax:
Practice Address - Street 1:43 LIBERTY DR
Practice Address - Street 2:
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-5635
Practice Address - Country:US
Practice Address - Phone:518-954-3354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002627-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant