Provider Demographics
NPI:1801496179
Name:DEITZ, DANIEL
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:DEITZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 HAINES AVE
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08009-2311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 NJ-73
Practice Address - Street 2:#80
Practice Address - City:WEST BERLIN
Practice Address - State:NJ
Practice Address - Zip Code:08091
Practice Address - Country:US
Practice Address - Phone:856-335-4938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01919600225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist