Provider Demographics
NPI:1316452980
Name:DIPERSIO, BETH
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:DIPERSIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:
Other - Last Name:BULLARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20 PEACHTREE CT STE 105
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-4616
Mailing Address - Country:US
Mailing Address - Phone:631-467-3700
Mailing Address - Fax:631-467-0928
Practice Address - Street 1:345 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12204-1001
Practice Address - Country:US
Practice Address - Phone:518-641-0958
Practice Address - Fax:518-641-0958
Is Sole Proprietor?:No
Enumeration Date:2017-12-05
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008860225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist