Provider Demographics
NPI:1073137287
Name:LICHTMAN, JEREMY (PT)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:LICHTMAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 GRANITE ST STE 3
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-5350
Mailing Address - Country:US
Mailing Address - Phone:781-961-3370
Mailing Address - Fax:781-961-1291
Practice Address - Street 1:26 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:MA
Practice Address - Zip Code:02368-4821
Practice Address - Country:US
Practice Address - Phone:781-961-9200
Practice Address - Fax:781-961-6599
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA24886225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist