Basic Information
| Provider Information | |||||||||
| NPI: | 1043768070 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIETRICH | ||||||||
| FirstName: | JOSEPH | ||||||||
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| Credential: | DPT, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1014 | ||||||||
| Address2: | |||||||||
| City: | CLARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070661014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7328559751 | ||||||||
| FaxNumber: | 7328559755 | ||||||||
| Practice Location | |||||||||
| Address1: | 4911 STELTON RD STE 3 | ||||||||
| Address2: | |||||||||
| City: | SOUTH PLAINFIELD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070801113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7325720021 | ||||||||
| FaxNumber: | 7328559755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2016 | ||||||||
| LastUpdateDate: | 08/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 225100000X | 40QA01936200 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.