Provider Demographics
NPI:1245308279
Name:DALINA, IDEL Q (RPT)
Entity type:Individual
Prefix:MR
First Name:IDEL
Middle Name:Q
Last Name:DALINA
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 E BROOKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-4804
Mailing Address - Country:US
Mailing Address - Phone:812-299-0529
Mailing Address - Fax:812-299-9779
Practice Address - Street 1:50 E BROOKSIDE DR
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-4804
Practice Address - Country:US
Practice Address - Phone:812-299-0529
Practice Address - Fax:812-299-9779
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05003440A225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN2002212100BMedicaid