Provider Demographics
NPI:1417683574
Name:DE KENIPP, STEVEN (PTA)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:DE KENIPP
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 COLUMBUS DR STE 300
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07302-3551
Mailing Address - Country:US
Mailing Address - Phone:201-366-1118
Mailing Address - Fax:201-359-3336
Practice Address - Street 1:115 COLUMBUS DR STE 300
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-3551
Practice Address - Country:US
Practice Address - Phone:201-366-1118
Practice Address - Fax:201-359-3336
Is Sole Proprietor?:No
Enumeration Date:2022-07-29
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00374200225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant