Healthcare Provider Details

I. General information

NPI: 1467280859
Provider Name (Legal Business Name): AMY LORRAINE DESROCHES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2024
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 OPTICAL DR
SOUTHBRIDGE MA
01550-2559
US

IV. Provider business mailing address

5 OPTICAL DR
SOUTHBRIDGE MA
01550-2559
US

V. Phone/Fax

Practice location:
  • Phone: 508-765-9101
  • Fax:
Mailing address:
  • Phone: 774-433-5413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number231088
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: