Provider Demographics
NPI:1922205368
Name:WEDELL, MARK (OT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WEDELL
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 N MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-2635
Mailing Address - Country:US
Mailing Address - Phone:516-809-5185
Mailing Address - Fax:
Practice Address - Street 1:400 W CUMMINGS PARK
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-6519
Practice Address - Country:US
Practice Address - Phone:781-933-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008197225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist