Provider Demographics
NPI:1497021802
Name:DITOMASSO, BRANDY (LMT)
Entity Type:Individual
Prefix:MRS
First Name:BRANDY
Middle Name:
Last Name:DITOMASSO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1069 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEICESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01524-1324
Mailing Address - Country:US
Mailing Address - Phone:508-892-5595
Mailing Address - Fax:
Practice Address - Street 1:1069 MAIN ST
Practice Address - Street 2:
Practice Address - City:LEICESTER
Practice Address - State:MA
Practice Address - Zip Code:01524-1324
Practice Address - Country:US
Practice Address - Phone:508-892-5595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9780171W00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No171W00000XOther Service ProvidersContractor