Provider Demographics
NPI:1487794483
Name:DIETEMAN, GEORGIANN LYNN (OTRL)
Entity type:Individual
Prefix:
First Name:GEORGIANN
Middle Name:LYNN
Last Name:DIETEMAN
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 COUNTRYSIDE LN
Mailing Address - Street 2:APARTMENT 5
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1339
Mailing Address - Country:US
Mailing Address - Phone:716-574-7183
Mailing Address - Fax:
Practice Address - Street 1:960 WEST MAPLE COURT
Practice Address - Street 2:
Practice Address - City:ELMA
Practice Address - State:NY
Practice Address - Zip Code:14059
Practice Address - Country:US
Practice Address - Phone:716-805-1555
Practice Address - Fax:716-805-1444
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0134411225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist