Provider Demographics
NPI:1679617096
Name:DAUTEL, SHARISE J (PT CERT MDT)
Entity Type:Individual
Prefix:MRS
First Name:SHARISE
Middle Name:J
Last Name:DAUTEL
Suffix:
Gender:F
Credentials:PT CERT MDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3411 SIVERSIDE ROAD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19810-4812
Mailing Address - Country:US
Mailing Address - Phone:302-478-5240
Mailing Address - Fax:
Practice Address - Street 1:3411 SILVERSIDE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19810-4812
Practice Address - Country:US
Practice Address - Phone:302-478-5240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-18
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0000414225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEG00716Medicare PIN
DE232003ZBSXMedicare PIN