Provider Demographics
NPI:1730677857
Name:DALLY, ADDOLORATA (PTA)
Entity Type:Individual
Prefix:
First Name:ADDOLORATA
Middle Name:
Last Name:DALLY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:NEW PROVIDENCE
Mailing Address - State:NJ
Mailing Address - Zip Code:07974-2012
Mailing Address - Country:US
Mailing Address - Phone:908-516-9300
Mailing Address - Fax:
Practice Address - Street 1:113 MADISON TER
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07081-3410
Practice Address - Country:US
Practice Address - Phone:908-721-6829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00267400225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant