Healthcare Provider Details

I. General information

NPI: 1427323625
Provider Name (Legal Business Name): MOLLY DEISROTH-KIM MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2012
Last Update Date: 03/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 2ND AVE SUITE 510
WALTHAM MA
02451-1132
US

IV. Provider business mailing address

20 GREEN WAY
WAYLAND MA
01778-2626
US

V. Phone/Fax

Practice location:
  • Phone: 781-487-6103
  • Fax:
Mailing address:
  • Phone: 508-358-4435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number127683
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: