Provider Demographics
NPI:1629461868
Name:DEPERMENTIER, JUSTIN JAMES (PT, DPT, ATC)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:JAMES
Last Name:DEPERMENTIER
Suffix:
Gender:M
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 PARK WAY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BROOMALL
Mailing Address - State:PA
Mailing Address - Zip Code:19008-4202
Mailing Address - Country:US
Mailing Address - Phone:484-422-8080
Mailing Address - Fax:484-422-8073
Practice Address - Street 1:450 PARK WAY
Practice Address - Street 2:SUITE A
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008-4202
Practice Address - Country:US
Practice Address - Phone:610-355-1780
Practice Address - Fax:484-428-3813
Is Sole Proprietor?:No
Enumeration Date:2015-03-12
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.022242225100000X
PAPT024201225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
426856YXTKMedicare PIN