Provider Demographics
NPI:1780215657
Name:BIDLACK, SETH (OT)
Entity type:Individual
Prefix:
First Name:SETH
Middle Name:
Last Name:BIDLACK
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 1:11154 ROAD 230
Mailing Address - Street 2:
Mailing Address - City:CECIL
Mailing Address - State:OH
Mailing Address - Zip Code:45821-9309
Mailing Address - Country:US
Mailing Address - Phone:419-438-5026
Mailing Address - Fax:
Practice Address - Street 1:11154 ROAD 230
Practice Address - Street 2:
Practice Address - City:CECIL
Practice Address - State:OH
Practice Address - Zip Code:45821-9309
Practice Address - Country:US
Practice Address - Phone:419-438-5026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-30
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT0039662255A2300X
IN31007078A225XP0019X
OHOT011233225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer