Provider Demographics
NPI:1457302325
Name:DIVITO, BARBARA (PA)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:
Last Name:DIVITO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 FREIGHT SHED RD
Mailing Address - Street 2:TEMPLETON DEVELOPMENTAL CENTER
Mailing Address - City:BALDWINVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:01436-1516
Mailing Address - Country:US
Mailing Address - Phone:978-939-2161
Mailing Address - Fax:978-939-1110
Practice Address - Street 1:212 FREIGHT SHED RD
Practice Address - Street 2:TEMPLETON DEVELOPMENTAL CENTER
Practice Address - City:BALDWINVILLE
Practice Address - State:MA
Practice Address - Zip Code:01436-1516
Practice Address - Country:US
Practice Address - Phone:978-939-2161
Practice Address - Fax:978-939-1110
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA681363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAP0199Medicare ID - Type Unspecified
MAS01034Medicare UPIN