Provider Demographics
NPI:1447395645
Name:DRISCHELL, DESMOND B (PTA)
Entity Type:Individual
Prefix:MR
First Name:DESMOND
Middle Name:B
Last Name:DRISCHELL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 E CENTER ST # 2663
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:SD
Mailing Address - Zip Code:57042-2908
Mailing Address - Country:US
Mailing Address - Phone:716-969-5158
Mailing Address - Fax:
Practice Address - Street 1:820 COTTAGE ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2426
Practice Address - Country:US
Practice Address - Phone:503-970-5498
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR09179225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant