Provider Demographics
NPI:1366056301
Name:PROBST, DEMETRI EUGENE
Entity type:Individual
Prefix:
First Name:DEMETRI
Middle Name:EUGENE
Last Name:PROBST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:248 SUSQUEHANNA AVE
Mailing Address - Street 2:
Mailing Address - City:RENOVO
Mailing Address - State:PA
Mailing Address - Zip Code:17764-1523
Mailing Address - Country:US
Mailing Address - Phone:570-786-7751
Mailing Address - Fax:
Practice Address - Street 1:248 SUSQUEHANNA AVE
Practice Address - Street 2:
Practice Address - City:RENOVO
Practice Address - State:PA
Practice Address - Zip Code:17764-1523
Practice Address - Country:US
Practice Address - Phone:570-786-7751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA390200000X
PART0078672255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program