Healthcare Provider Details

I. General information

NPI: 1922913276
Provider Name (Legal Business Name): MATTHEW DETTLEFF
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 JOMAR RD
SHOREHAM NY
11786-1937
US

IV. Provider business mailing address

47 JOMAR RD
SHOREHAM NY
11786-1937
US

V. Phone/Fax

Practice location:
  • Phone: 631-566-2831
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number021793
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: