Provider Demographics
NPI:1629384730
Name:FEDERICO, DAYLE J (BSPT)
Entity Type:Individual
Prefix:
First Name:DAYLE
Middle Name:J
Last Name:FEDERICO
Suffix:
Gender:F
Credentials:BSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10325 BUENA VENTURA DR
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33498-6711
Mailing Address - Country:US
Mailing Address - Phone:609-204-4849
Mailing Address - Fax:609-653-1258
Practice Address - Street 1:116 MARSHALL DR
Practice Address - Street 2:
Practice Address - City:EGG HARBOR TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08234-6008
Practice Address - Country:US
Practice Address - Phone:609-204-4849
Practice Address - Fax:609-653-1258
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-26
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00698800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT27580OtherSTATE LICENSE
NJ40QA00698800OtherSTATE LICENSE