Provider Demographics
NPI:1790848075
Name:BIDLACK, DONNA (MACCC SLP)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:BIDLACK
Suffix:
Gender:F
Credentials:MACCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W 174 GROVER CENTER
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701
Mailing Address - Country:US
Mailing Address - Phone:740-593-1404
Mailing Address - Fax:740-593-4433
Practice Address - Street 1:OHIO UNIVERSITY THERAPY ASSOC
Practice Address - Street 2:W174 GROVER CENTER
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701
Practice Address - Country:US
Practice Address - Phone:740-593-1404
Practice Address - Fax:740-593-4433
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP1937235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000246469OtherANTHEM
OH0624471Medicaid