Healthcare Provider Details

I. General information

NPI: 1790703718
Provider Name (Legal Business Name): PAUL MICHAEL DELLAVECCHIA MSPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 11/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 CENTENNIAL BLVD BLDG 2
VOORHEES NJ
08043-4637
US

IV. Provider business mailing address

1 FEDERAL STREET SW 100
CAMDEN NJ
08103
US

V. Phone/Fax

Practice location:
  • Phone: 856-325-6677
  • Fax: 856-325-6678
Mailing address:
  • Phone: 856-356-4924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA00867100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: