Provider Demographics
NPI:1720455850
Name:WALLENSTEIN, DANIEL LEO (DPT, LPT)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:LEO
Last Name:WALLENSTEIN
Suffix:
Gender:M
Credentials:DPT, LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 CONGER ST APT 203A
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-3314
Mailing Address - Country:US
Mailing Address - Phone:917-837-7602
Mailing Address - Fax:
Practice Address - Street 1:590 ANDERSON AVE
Practice Address - Street 2:
Practice Address - City:CLIFFSIDE PARK
Practice Address - State:NJ
Practice Address - Zip Code:07010-1721
Practice Address - Country:US
Practice Address - Phone:201-941-8667
Practice Address - Fax:201-941-3353
Is Sole Proprietor?:No
Enumeration Date:2015-08-24
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
NJ40QA01915600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer