MEDICARE: TARSHE DERIVAL M.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1639493059
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARSHE DERIVAL M.A.

Provider Business Mailing Address
First Line	:	2216 DORCHESTER AVE
Second Line	:
City	:	DORCHESTER
State	:	MA
Zip	:	02124-5607
Country	:	US
Telephone Number	:	857-445-2034
Fax Number	:

Provider Business Practice Location Address
First Line	:	2216 DORCHESTER AVE
Second Line	:
City	:	DORCHESTER
State	:	MA
Zip	:	02124-5607
Country	:	US
Telephone Number	:	617-322-3380
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/15/2010
Last Update Date	:	08/13/2014

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