Provider Demographics
NPI:1710477468
Name:DICENSO, PHILIP M (DPT)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:M
Last Name:DICENSO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3760 CONVOY ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-3743
Mailing Address - Country:US
Mailing Address - Phone:888-208-8526
Mailing Address - Fax:858-751-0901
Practice Address - Street 1:1020 TIERRA DEL REY STE A-1
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-7886
Practice Address - Country:US
Practice Address - Phone:619-585-7104
Practice Address - Fax:619-585-7106
Is Sole Proprietor?:No
Enumeration Date:2018-05-17
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3581225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist