Basic Information
| Provider Information | |||||||||
| NPI: | 1508195116 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIVINCENZO | ||||||||
| FirstName: | PAULA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1423 WORTON BLVD | ||||||||
| Address2: | |||||||||
| City: | MAYFIELD HTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441241741 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 10 SEVERANCE CIR | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441181533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165247377 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2009 | ||||||||
| LastUpdateDate: | 07/20/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 012072 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 15081951116 | 01 | OH | NPI | OTHER |