Provider Demographics
NPI:1821370164
Name:WINGENBACH, M. DAVEDA (PT)
Entity Type:Individual
Prefix:MRS
First Name:M. DAVEDA
Middle Name:
Last Name:WINGENBACH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PENNELLVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13132-3143
Mailing Address - Country:US
Mailing Address - Phone:315-668-8152
Mailing Address - Fax:
Practice Address - Street 1:195 BLACKBERRY RD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090-3047
Practice Address - Country:US
Practice Address - Phone:315-622-7160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007377225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist