Provider Demographics
NPI:1528778420
Name:BENTZ, NICHOLAS JACK (DPT)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JACK
Last Name:BENTZ
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5425 JONESTOWN RD STE 100
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17112-4086
Mailing Address - Country:US
Mailing Address - Phone:717-901-6487
Mailing Address - Fax:
Practice Address - Street 1:722 ALLEGHENY ST STE 2
Practice Address - Street 2:
Practice Address - City:DAUPHIN
Practice Address - State:PA
Practice Address - Zip Code:17018-8902
Practice Address - Country:US
Practice Address - Phone:717-474-8754
Practice Address - Fax:717-474-8755
Is Sole Proprietor?:No
Enumeration Date:2022-12-01
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT030860225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist