Provider Demographics
NPI:1245777697
Name:DEMELLO, DENISE
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:DEMELLO
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 1:3000 GOFFS FALLS RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03111-1000
Mailing Address - Country:US
Mailing Address - Phone:800-995-2673
Mailing Address - Fax:
Practice Address - Street 1:3000 GOFFS FALLS RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03111-1000
Practice Address - Country:US
Practice Address - Phone:800-995-2673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-24
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT14285225X00000X
MA11511225X00000X
AK120741225X00000X
HIOT-1626225X00000X
MD08345225X00000X
CA17501225X00000X
TX118118225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist