Provider Demographics
NPI:1548966443
Name:DEDERICK, DYLAN EVAN (PT, DPT)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:EVAN
Last Name:DEDERICK
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 FARM POND RD
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027-9062
Mailing Address - Country:US
Mailing Address - Phone:845-901-3798
Mailing Address - Fax:
Practice Address - Street 1:765 W NASA BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1815
Practice Address - Country:US
Practice Address - Phone:321-733-5725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-01
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT37927225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist