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General NPI Number Information
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NPI Number | 1871964270
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Entity Type | Individual
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Provider Name | MICHAEL DEZMIN
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Gender | Male
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Dates
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Enumeration Date | 10/12/2015
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Last Update Date | 10/12/2015
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Provider Practice Location Address
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Address Line | 74 BRIDGE ST
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City | NEWTON
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State | MA
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Zip | 02458-1147
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Country | US
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Telephone | 617-969-4410
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Fax | 617-969-4412
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Provider Business Mailing Address
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Address Line | 25 ROSE AVE
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City | WATERTOWN
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State | MA
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Zip | 02472-3012
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225XP0200X
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Taxonomy Name | Pediatric Occupational Therapist
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License Number | 11767
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License Number State | MA
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