Provider Demographics
NPI:1891825618
Name:WARMUTH, JACQUELINE D (OTR)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:D
Last Name:WARMUTH
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9231 SHELLEY DR
Mailing Address - Street 2:
Mailing Address - City:MARCY
Mailing Address - State:NY
Mailing Address - Zip Code:13403-2623
Mailing Address - Country:US
Mailing Address - Phone:315-797-3114
Mailing Address - Fax:315-624-0474
Practice Address - Street 1:2050 TILDEN AVE
Practice Address - Street 2:BOX 1000
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-3613
Practice Address - Country:US
Practice Address - Phone:315-797-3114
Practice Address - Fax:315-624-0474
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005185-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01815443Medicaid
NY00313539Medicaid
NY334526Medicare Oscar/Certification
NY01815443Medicaid