Provider Demographics
NPI:1619583135
Name:DIBLANDA, JENNA ROSE (OTR/L)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:ROSE
Last Name:DIBLANDA
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 1:500 BEDFORD ST APT 445
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06901-1525
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 BEDFORD ST APT 445
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06901-1525
Practice Address - Country:US
Practice Address - Phone:631-338-8302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024971225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist