Provider Demographics
NPI:1003512401
Name:DIETRICH, GERALD
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:
Last Name:DIETRICH
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:PO BOX 870
Mailing Address - Street 2:
Mailing Address - City:HUNTINGDON
Mailing Address - State:PA
Mailing Address - Zip Code:16652-0870
Mailing Address - Country:US
Mailing Address - Phone:814-506-8212
Mailing Address - Fax:814-506-8213
Practice Address - Street 1:4112 SPRINGHILL RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:PA
Practice Address - Zip Code:15946-7402
Practice Address - Country:US
Practice Address - Phone:814-506-8212
Practice Address - Fax:814-506-8213
Is Sole Proprietor?:No
Enumeration Date:2023-02-07
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT030043225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist