Provider Demographics
NPI:1003129156
Name:DIMENNO, HEATHER (PT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:DIMENNO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 416495
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-6495
Mailing Address - Country:US
Mailing Address - Phone:631-580-5200
Mailing Address - Fax:631-580-5222
Practice Address - Street 1:452 US HIGHWAY 206
Practice Address - Street 2:
Practice Address - City:MONTAGUE
Practice Address - State:NJ
Practice Address - Zip Code:07827-3045
Practice Address - Country:US
Practice Address - Phone:973-293-0010
Practice Address - Fax:973-293-0018
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01358100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist