Provider Demographics
NPI:1164260667
Name:DESROCHES, SIMONE ELIZABETH
Entity type:Individual
Prefix:
First Name:SIMONE
Middle Name:ELIZABETH
Last Name:DESROCHES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 RUSSELL TRUFANT RD
Mailing Address - Street 2:
Mailing Address - City:CARVER
Mailing Address - State:MA
Mailing Address - Zip Code:02330-1030
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-7243
Practice Address - Country:US
Practice Address - Phone:774-608-7253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAOTL15379225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics