Basic Information
Provider Information | |||||||||
NPI: | 1386650240 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DENTREMONT | ||||||||
FirstName: | ELIZABETH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 250 LANCANTER AVE | ||||||||
Address2: | #225 | ||||||||
City: | PAOLI | ||||||||
State: | PA | ||||||||
PostalCode: | 19301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6106518282 | ||||||||
FaxNumber: | 6106518283 | ||||||||
Practice Location | |||||||||
Address1: | 250 LANCANTER AVE | ||||||||
Address2: | #225 | ||||||||
City: | PAOLI | ||||||||
State: | PA | ||||||||
PostalCode: | 19301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6106518282 | ||||||||
FaxNumber: | 6106518283 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/31/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X |   |   | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
ID | Type | State | Issuer | Description | 2284912000 | 01 |   | PERSONAL CHOICE 65 | OTHER | 1606882 | 01 |   | BLUE CROSS BLUE SHIELD | OTHER |