Provider Demographics
NPI:1093386252
Name:CORONA, DYLAN JAMES (LMT, CPT, CES)
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:JAMES
Last Name:CORONA
Suffix:
Gender:M
Credentials:LMT, CPT, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 LONG BRANCH AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07740-7564
Mailing Address - Country:US
Mailing Address - Phone:848-459-3342
Mailing Address - Fax:
Practice Address - Street 1:214 PARK AVE
Practice Address - Street 2:
Practice Address - City:MANALAPAN
Practice Address - State:NJ
Practice Address - Zip Code:07726-8372
Practice Address - Country:US
Practice Address - Phone:848-459-3342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT01235700225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist