Healthcare Provider Details

I. General information

NPI: 1538270137
Provider Name (Legal Business Name): DIANE J. WOOLDRIDGE, PHYSICAL THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 01/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3507 POST ST
CLINTON NY
13323-4716
US

IV. Provider business mailing address

3507 POST ST
CLINTON NY
13323-4716
US

V. Phone/Fax

Practice location:
  • Phone: 315-853-1401
  • Fax: 315-853-7629
Mailing address:
  • Phone: 315-853-1401
  • Fax: 315-853-7629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number009744-1
License Number StateNY

VIII. Authorized Official

Name: DIANE J WOOLDRIDGE
Title or Position: PT/SOLE PROPRIETOR
Credential: PT
Phone: 315-853-1401