Provider Demographics
NPI:1184715229
Name:ETTENBERGER, DEIDRA ONALEE (PTA)
Entity type:Individual
Prefix:
First Name:DEIDRA
Middle Name:ONALEE
Last Name:ETTENBERGER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 STEUBEN ST
Mailing Address - Street 2:
Mailing Address - City:MONTOUR FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14865
Mailing Address - Country:US
Mailing Address - Phone:607-535-8616
Mailing Address - Fax:607-210-1965
Practice Address - Street 1:220 STEUBEN ST
Practice Address - Street 2:SCHUYLER HOSPITAL
Practice Address - City:MONTOUR FALLS
Practice Address - State:NY
Practice Address - Zip Code:14865
Practice Address - Country:US
Practice Address - Phone:607-535-7121
Practice Address - Fax:607-210-1965
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0053481225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant