Provider Demographics
NPI:1508195116
Name:DIVINCENZO, PAULA L (PT)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:L
Last Name:DIVINCENZO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1423 WORTON BLVD
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44124-1741
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 SEVERANCE CIR
Practice Address - Street 2:
Practice Address - City:CLEVELAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44118-1533
Practice Address - Country:US
Practice Address - Phone:216-524-7377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-10
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH012072225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH15081951116OtherNPI