Provider Demographics
NPI:1275663304
Name:DIERS, DANIEL WENDELL (MPT, ATC)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:WENDELL
Last Name:DIERS
Suffix:
Gender:M
Credentials:MPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 MERCHANT CIR
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39437-8709
Mailing Address - Country:US
Mailing Address - Phone:601-319-1518
Mailing Address - Fax:
Practice Address - Street 1:23 MASON ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4437
Practice Address - Country:US
Practice Address - Phone:601-399-0534
Practice Address - Fax:601-425-7585
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3215225100000X
MSAT02742255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer