Provider Demographics
NPI:1689682643
Name:WODASKI, BRYAN JOHN (MS OTRL CHT)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:JOHN
Last Name:WODASKI
Suffix:
Gender:M
Credentials:MS OTRL CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1517
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21501-1517
Mailing Address - Country:US
Mailing Address - Phone:301-759-6317
Mailing Address - Fax:301-759-4461
Practice Address - Street 1:200 GLENN STREET
Practice Address - Street 2:STE 200
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502
Practice Address - Country:US
Practice Address - Phone:301-759-4263
Practice Address - Fax:301-759-4461
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03241225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0159766000Medicaid
S68127Medicare UPIN
WV0159766000Medicaid
732M278FMedicare PIN