Provider Demographics
NPI:1790586253
Name:DIETZ, DOMINIQUE MARIE
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:MARIE
Last Name:DIETZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 STANBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:HOLMES
Mailing Address - State:PA
Mailing Address - Zip Code:19043-1421
Mailing Address - Country:US
Mailing Address - Phone:610-212-2090
Mailing Address - Fax:
Practice Address - Street 1:4643 W CHESTER PIKE
Practice Address - Street 2:
Practice Address - City:NEWTOWN SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19073-2226
Practice Address - Country:US
Practice Address - Phone:610-871-0188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-21
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty