Healthcare Provider Details

I. General information

NPI: 1194710756
Provider Name (Legal Business Name): JOSEPH DATTILO PT, C.PED
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 05/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 PORTSMOUTH AVE SUITE 5
STRATHAM NH
03885-2523
US

IV. Provider business mailing address

210 COMMERCE WAY STE. 120
PORTSMOUTH NH
03801-8200
US

V. Phone/Fax

Practice location:
  • Phone: 603-772-8222
  • Fax: 603-772-6738
Mailing address:
  • Phone: 603-427-8066
  • Fax: 603-501-0495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1866
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: