Provider Demographics
NPI:1770558884
Name:DIETRICH, HARRY (PT)
Entity type:Individual
Prefix:
First Name:HARRY
Middle Name:
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 HILLSIDE AVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040
Mailing Address - Country:US
Mailing Address - Phone:516-354-9250
Mailing Address - Fax:516-358-5359
Practice Address - Street 1:1575 HILLSIDE AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040
Practice Address - Country:US
Practice Address - Phone:516-354-9250
Practice Address - Fax:516-358-5359
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0120811225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
QQ0162Medicare ID - Type Unspecified