Provider Demographics
NPI:1700406824
Name:WIDENER, BAILEY R (OTR/L)
Entity Type:Individual
Prefix:
First Name:BAILEY
Middle Name:R
Last Name:WIDENER
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 1:524 KENYON ST NW APT 33
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20010-2937
Mailing Address - Country:US
Mailing Address - Phone:913-952-1053
Mailing Address - Fax:
Practice Address - Street 1:110 IRVING ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-3017
Practice Address - Country:US
Practice Address - Phone:202-877-6316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-18
Last Update Date:2020-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCOT010001510225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist