Provider Demographics
NPI:1174039788
Name:DESIR, MICHAELA LANAE
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:LANAE
Last Name:DESIR
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 1:26 AVE AT PORT IMPERIAL APT 226
Mailing Address - Street 2:
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-8392
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 COLUMBUS DR STE 300
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-3551
Practice Address - Country:US
Practice Address - Phone:201-366-1115
Practice Address - Fax:201-366-1117
Is Sole Proprietor?:No
Enumeration Date:2017-12-19
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA02003300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist