Provider Demographics
NPI:1336292440
Name:DEISENROTH, CARRIE LYNN (ATC)
Entity Type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:LYNN
Last Name:DEISENROTH
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 MARLBORO RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01772-1207
Mailing Address - Country:US
Mailing Address - Phone:508-786-6144
Mailing Address - Fax:508-786-6139
Practice Address - Street 1:25 MARLBORO RD
Practice Address - Street 2:
Practice Address - City:SOUTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01772-1207
Practice Address - Country:US
Practice Address - Phone:508-786-6144
Practice Address - Fax:508-786-6139
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10722255A2300X
NY67 0004572255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer