Provider Demographics
NPI:1619020112
Name:DEITRICH, PATRICIA
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:DEITRICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 PHILADELPHIA ST
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-3902
Mailing Address - Country:US
Mailing Address - Phone:724-463-7478
Mailing Address - Fax:724-463-0931
Practice Address - Street 1:1000 MARKET ST
Practice Address - Street 2:SUITE 11
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-2600
Practice Address - Country:US
Practice Address - Phone:570-784-1896
Practice Address - Fax:570-784-1897
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT005500L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA34765OtherHIGHMARK BLUE SHIELD
PA547051OtherHEALTH AMER.ASSUR.
PA50066058OtherKHPC-CAPITAL
PA547051OtherHEALTH AMER.ASSUR.