Healthcare Provider Details

I. General information

NPI: 1124489562
Provider Name (Legal Business Name): MICHAEL DEFOSSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2016
Last Update Date: 03/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 ARLINGTON BLVD APT 1031 SUITE 1031
ARLINGTON VA
22209-2210
US

IV. Provider business mailing address

1011 ARLINGTON BLVD APT 1031 SUITE 1031
ARLINGTON VA
22209-2210
US

V. Phone/Fax

Practice location:
  • Phone: 617-699-3527
  • Fax:
Mailing address:
  • Phone: 617-699-3527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License Number8852
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License Number8852
License Number StateMA

VIII. Authorized Official

Name: MR. MICHAEL S DEFOSSE
Title or Position: OCCUPATIONAL THERAPIST
Credential:
Phone: 617-699-3527