Provider Demographics
NPI:1619187424
Name:DELA CUESTA, THEA OMEGA JARDINIANO (PT)
Entity Type:Individual
Prefix:
First Name:THEA OMEGA
Middle Name:JARDINIANO
Last Name:DELA CUESTA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:THEA OMEGA
Other - Middle Name:MANGUBAT
Other - Last Name:JARDINIANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:482 LAWRENCE ST
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07607-1260
Mailing Address - Country:US
Mailing Address - Phone:201-880-6258
Mailing Address - Fax:
Practice Address - Street 1:125 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DUMONT
Practice Address - State:NJ
Practice Address - Zip Code:07628-3066
Practice Address - Country:US
Practice Address - Phone:201-385-6272
Practice Address - Fax:201-385-7410
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01055700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist