Provider Demographics
NPI:1417503855
Name:DINICOLA, GARRETT ADIN (DPT)
Entity Type:Individual
Prefix:
First Name:GARRETT
Middle Name:ADIN
Last Name:DINICOLA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 JORDAN ST STE 150
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4529
Mailing Address - Country:US
Mailing Address - Phone:318-222-7442
Mailing Address - Fax:318-424-4751
Practice Address - Street 1:820 JORDAN ST STE 150
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4529
Practice Address - Country:US
Practice Address - Phone:318-222-7442
Practice Address - Fax:318-424-4751
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10334225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist