Healthcare Provider Details

I. General information

NPI: 1679617096
Provider Name (Legal Business Name): SHARISE J DAUTEL PT CERT. MDT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2007
Last Update Date: 01/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3411 SILVERSIDE RD SUITE 105
WILMINGTON DE
19810-4812
US

IV. Provider business mailing address

3411 SIVERSIDE ROAD SUITE 105
WILMINGTON DE
19810-4812
US

V. Phone/Fax

Practice location:
  • Phone: 302-478-5240
  • Fax:
Mailing address:
  • Phone: 302-478-5240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberJ1-0000414
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: