Provider Demographics
NPI:1710363783
Name:DEWALD, DONALD JR (PTA)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:
Last Name:DEWALD
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1859 ALAMO AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-6001
Mailing Address - Country:US
Mailing Address - Phone:937-624-5142
Mailing Address - Fax:
Practice Address - Street 1:1859 ALAMO AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-6001
Practice Address - Country:US
Practice Address - Phone:937-624-5142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-31
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA09182225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant