Provider Demographics
NPI:1629775911
Name:SUPPLE, DANIEL JAMES (PT,DPT)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JAMES
Last Name:SUPPLE
Suffix:
Gender:M
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:924 JEFFERSON ST APT 3A
Mailing Address - Street 2:
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-9239
Mailing Address - Country:US
Mailing Address - Phone:973-722-6293
Mailing Address - Fax:
Practice Address - Street 1:535 EST 60TH STREET, 2ND FLOOR
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021
Practice Address - Country:US
Practice Address - Phone:212-606-1213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-08
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048829-01225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist