1124072624 NPI number — LILLIAN KATHLEEN DETWILER P.T.

Table of content: LILLIAN KATHLEEN DETWILER P.T. (NPI 1124072624)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124072624 NPI number — LILLIAN KATHLEEN DETWILER P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DETWILER
Provider First Name:
LILLIAN
Provider Middle Name:
KATHLEEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124072624
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
730 S BROAD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANSDALE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19446-5211
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
267-663-7767
Provider Business Mailing Address Fax Number:
267-222-8158

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1835 E RIDGE PIKE STE 30
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROYERSFORD
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19468-2818
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-409-5655
Provider Business Practice Location Address Fax Number:
610-489-4874
Provider Enumeration Date:
05/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT016109 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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