Provider Demographics
NPI:1790703718
Name:DELLAVECCHIA, PAUL MICHAEL (MSPT)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:MICHAEL
Last Name:DELLAVECCHIA
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FEDERAL STREET
Mailing Address - Street 2:SW 100
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103
Mailing Address - Country:US
Mailing Address - Phone:856-356-4924
Mailing Address - Fax:
Practice Address - Street 1:900 CENTENNIAL BLVD BLDG 2
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4637
Practice Address - Country:US
Practice Address - Phone:856-325-6677
Practice Address - Fax:856-325-6678
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00867100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJPCV041962Medicare ID - Type Unspecified