Provider Demographics
NPI:1114241718
Name:DIMITRAKAKIS, STELLA (DPT)
Entity Type:Individual
Prefix:
First Name:STELLA
Middle Name:
Last Name:DIMITRAKAKIS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 GALLOPING HILL RD STE 203
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-7989
Mailing Address - Country:US
Mailing Address - Phone:908-522-6420
Mailing Address - Fax:
Practice Address - Street 1:1000 GALLOPING HILL RD STE 203
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-7989
Practice Address - Country:US
Practice Address - Phone:908-522-6420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-25
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01346800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ40QA01330500OtherNEW JERSEY BOARD OF PHYSICAL THERAPY