Provider Demographics
NPI:1699904037
Name:DZIEDZIAK, BRENDA JEAN (COTA)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:JEAN
Last Name:DZIEDZIAK
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 SCHUYLKILL MANOR RD
Mailing Address - Street 2:
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-3862
Mailing Address - Country:US
Mailing Address - Phone:570-624-3228
Mailing Address - Fax:
Practice Address - Street 1:1000 SCHUYLKILL MANOR RD
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-3862
Practice Address - Country:US
Practice Address - Phone:570-624-3228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-07
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP006613224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant