Provider Demographics
NPI:1538270137
Name:DIANE J. WOOLDRIDGE, PHYSICAL THERAPY, PLLC
Entity type:Organization
Organization Name:DIANE J. WOOLDRIDGE, PHYSICAL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT/SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:J
Authorized Official - Last Name:WOOLDRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:315-853-1401
Mailing Address - Street 1:3507 POST ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NY
Mailing Address - Zip Code:13323-4716
Mailing Address - Country:US
Mailing Address - Phone:315-853-1401
Mailing Address - Fax:315-853-7629
Practice Address - Street 1:3507 POST ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NY
Practice Address - Zip Code:13323-4716
Practice Address - Country:US
Practice Address - Phone:315-853-1401
Practice Address - Fax:315-853-7629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009744-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP010009744OtherBC/BS
NY435741OtherMVP
NY02302078Medicaid
NY650024491OtherRAILROAD MEDICARE
NYP010009744OtherBC/BS
NYAA1465Medicare ID - Type UnspecifiedGROUP
NYS65478Medicare UPIN
NYDD4016Medicare ID - Type UnspecifiedINDIVIDUAL