Provider Demographics
NPI:1518332816
Name:DIVERSIFIED SERVICES FOR OCCUPATIONAL THERAPY PHYSICAL THER
Entity Type:Organization
Organization Name:DIVERSIFIED SERVICES FOR OCCUPATIONAL THERAPY PHYSICAL THER
Other - Org Name:CHILDREN'S REHAB SERVICES OF WNY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF CHILDREN'S SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:MADONNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:RUGGIERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-871-9883
Mailing Address - Street 1:2900 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14217-2309
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2900 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-2309
Practice Address - Country:US
Practice Address - Phone:716-871-9883
Practice Address - Fax:716-256-1675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-11
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02995691Medicaid