Provider Demographics
NPI:1700077948
Name:SIDWAY, ROBERT ARTHUR (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:ARTHUR
Last Name:SIDWAY
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 E 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:TRUTH OR CONSEQUENCES
Mailing Address - State:NM
Mailing Address - Zip Code:87901-1902
Mailing Address - Country:US
Mailing Address - Phone:505-894-6923
Mailing Address - Fax:
Practice Address - Street 1:992 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:TRUTH OR CONSEQUENCES
Practice Address - State:NM
Practice Address - Zip Code:87901-3198
Practice Address - Country:US
Practice Address - Phone:505-894-4269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2006225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist