Provider Demographics
NPI:1235015041
Name:DIAS, DEIDRE- ANN RONIQUE
Entity type:Individual
Prefix:
First Name:DEIDRE- ANN
Middle Name:RONIQUE
Last Name:DIAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:NJ
Mailing Address - Zip Code:07940-1861
Mailing Address - Country:US
Mailing Address - Phone:908-443-9880
Mailing Address - Fax:
Practice Address - Street 1:78 MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:NJ
Practice Address - Zip Code:07940-1861
Practice Address - Country:US
Practice Address - Phone:908-443-9880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-15
Last Update Date:2025-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00425600225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant