Basic Information
| Provider Information | |||||||||
| NPI: | 1558001834 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEDONATO | ||||||||
| FirstName: | DINA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MSPT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | GATHWRIGHT | ||||||||
| OtherFirstName: | DINA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 14050 N 83RD AVE STE 290 | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853815650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668396979 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 14050 N 83RD AVE STE 290 | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853815650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668396979 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2022 | ||||||||
| LastUpdateDate: | 04/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 4098 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.