Healthcare Provider Details

I. General information

NPI: 1699670695
Provider Name (Legal Business Name): TATIANA WIERSMA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

536 HAWTHORN ST
DARTMOUTH MA
02747-3717
US

IV. Provider business mailing address

576 BROADHOLLOW RD
MELVILLE NY
11747-5012
US

V. Phone/Fax

Practice location:
  • Phone: 508-286-7129
  • Fax:
Mailing address:
  • Phone: 631-359-5859
  • Fax: 631-359-5859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: