Provider Demographics
NPI:1518352558
Name:FERNANDES, DERITH (DPT)
Entity Type:Individual
Prefix:
First Name:DERITH
Middle Name:
Last Name:FERNANDES
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 FREDRICKSON RD
Mailing Address - Street 2:
Mailing Address - City:BILLERICA
Mailing Address - State:MA
Mailing Address - Zip Code:01821-5313
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:414 MAIN ST
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01880-3018
Practice Address - Country:US
Practice Address - Phone:781-245-0055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21572225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist