Provider Demographics
NPI:1851975221
Name:DIAZ, DELIA VANESSA (DPT)
Entity Type:Individual
Prefix:
First Name:DELIA
Middle Name:VANESSA
Last Name:DIAZ
Suffix:
Gender:F
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:PO BOX 416495
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5814
Mailing Address - Country:US
Mailing Address - Phone:631-580-5200
Mailing Address - Fax:631-760-8306
Practice Address - Street 1:1255 BROAD ST STE 207
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-3061
Practice Address - Country:US
Practice Address - Phone:973-893-9300
Practice Address - Fax:973-893-0073
Is Sole Proprietor?:No
Enumeration Date:2021-05-11
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA02005600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist