Provider Demographics
NPI:1184011967
Name:DIETZE, THOMAS (COTA/L)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:DIETZE
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 VALLEY STREAM RD
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-2820
Mailing Address - Country:US
Mailing Address - Phone:908-217-0981
Mailing Address - Fax:
Practice Address - Street 1:1035 VALLEY STREAM RD
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-2820
Practice Address - Country:US
Practice Address - Phone:908-217-0981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-20
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TA09009500224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant