Provider Demographics
NPI:1285909507
Name:NEIDICH, JUSTIN (LPT)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:NEIDICH
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7465 NW 1ST MNR
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33317-2270
Mailing Address - Country:US
Mailing Address - Phone:954-213-8194
Mailing Address - Fax:
Practice Address - Street 1:3434 NE 12TH AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33334-4523
Practice Address - Country:US
Practice Address - Phone:954-900-8842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-20
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01437200225100000X
FLPT35221225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT35221OtherDEPARTMENT OF HEALTH