Provider Demographics
NPI:1992938112
Name:WIDRICK OCCUPATIONAL THERAPY SERVICES, PLLC
Entity type:Organization
Organization Name:WIDRICK OCCUPATIONAL THERAPY SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:WIDRICK
Authorized Official - Suffix:
Authorized Official - Credentials:MS, OTR/L
Authorized Official - Phone:919-815-4389
Mailing Address - Street 1:105 CANTERSTONE CT
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-2251
Mailing Address - Country:US
Mailing Address - Phone:919-815-4389
Mailing Address - Fax:
Practice Address - Street 1:105 CANTERSTONE CT
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-2251
Practice Address - Country:US
Practice Address - Phone:919-815-4389
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-03
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4143225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty