Provider Demographics
NPI:1194069674
Name:DETWEILER, JODY (PTA)
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:DETWEILER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 UPPER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GREEN LANE
Mailing Address - State:PA
Mailing Address - Zip Code:18054-9418
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 NORTHPOINTE CIR
Practice Address - Street 2:SUITE 302
Practice Address - City:SEVEN FIELDS
Practice Address - State:PA
Practice Address - Zip Code:16046-7861
Practice Address - Country:US
Practice Address - Phone:215-257-2751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-21
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE1002850225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant