Provider Demographics
NPI:1346600814
Name:DESIMONE, TRIESSA (MPA, LMT)
Entity Type:Individual
Prefix:
First Name:TRIESSA
Middle Name:
Last Name:DESIMONE
Suffix:
Gender:F
Credentials:MPA, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 LAWN ST
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07656-1119
Mailing Address - Country:US
Mailing Address - Phone:201-421-8781
Mailing Address - Fax:
Practice Address - Street 1:101 LAWN ST
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07656-1119
Practice Address - Country:US
Practice Address - Phone:201-421-8781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-26
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT00602800225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist