Healthcare Provider Details

I. General information

NPI: 1457420440
Provider Name (Legal Business Name): ARMAND W DETHOMAS JR. DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 N MAIN ST
GLASSBORO NJ
08028-1605
US

IV. Provider business mailing address

115 MAIN ST
CEDARVILLE NJ
08311-2535
US

V. Phone/Fax

Practice location:
  • Phone: 856-307-9700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01224300
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT021695
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: