Provider Demographics
NPI:1689021859
Name:OBIDIENZO, NICHOLAS ROGER III (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:ROGER
Last Name:OBIDIENZO
Suffix:III
Gender:M
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 1:15050 14TH RD
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-2609
Mailing Address - Country:US
Mailing Address - Phone:718-767-0091
Mailing Address - Fax:
Practice Address - Street 1:15050 14TH RD
Practice Address - Street 2:
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357-2609
Practice Address - Country:US
Practice Address - Phone:718-767-0091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020456-1225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics