Provider Demographics
NPI:1780215657
Name:BIDLACK, SETH
Entity Type:Individual
Prefix:
First Name:SETH
Middle Name:
Last Name:BIDLACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2626 ST. JOE CENTER RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYEN
Mailing Address - State:IN
Mailing Address - Zip Code:46825
Mailing Address - Country:US
Mailing Address - Phone:260-497-0328
Mailing Address - Fax:
Practice Address - Street 1:2626 ST. JOE CENTER RD
Practice Address - Street 2:
Practice Address - City:FORT WAYEN
Practice Address - State:IN
Practice Address - Zip Code:46825
Practice Address - Country:US
Practice Address - Phone:260-497-0328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31007078A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist