Provider Demographics
NPI:1952795148
Name:DE LA PENA, JUSTIN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:DE LA PENA
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DUMONT
Mailing Address - State:NJ
Mailing Address - Zip Code:07628-1718
Mailing Address - Country:US
Mailing Address - Phone:646-535-7362
Mailing Address - Fax:
Practice Address - Street 1:142 JOHN ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-4130
Practice Address - Country:US
Practice Address - Phone:201-342-1404
Practice Address - Fax:201-342-1867
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-25
Last Update Date:2015-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01588300225100000X
NY0387341225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist