Provider Demographics
NPI:1528368255
Name:NEIDIG, TRISTY (PTA)
Entity Type:Individual
Prefix:MS
First Name:TRISTY
Middle Name:
Last Name:NEIDIG
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 YOUNG AVE
Mailing Address - Street 2:
Mailing Address - City:TOTOWA
Mailing Address - State:NJ
Mailing Address - Zip Code:07512-2036
Mailing Address - Country:US
Mailing Address - Phone:724-664-7613
Mailing Address - Fax:
Practice Address - Street 1:140 SHEPHERD LN
Practice Address - Street 2:
Practice Address - City:TOTOWA
Practice Address - State:NJ
Practice Address - Zip Code:07512-2188
Practice Address - Country:US
Practice Address - Phone:724-664-7613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-28
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00251100225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant