Healthcare Provider Details

I. General information

NPI: 1073761342
Provider Name (Legal Business Name): JOI DERISMA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JOI DERISMA LMT

II. Dates (important events)

Enumeration Date: 08/28/2008
Last Update Date: 08/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5961 NW 173RD DR
HIALEAH FL
33015-5114
US

IV. Provider business mailing address

8912 W FLAGLER ST #203
MIAMI FL
33174-3950
US

V. Phone/Fax

Practice location:
  • Phone: 305-556-7500
  • Fax:
Mailing address:
  • Phone: 954-918-7180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA33160
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: