Provider Demographics
NPI:1659674349
Name:DESERPA, ANTHONY VICTOR (M ED)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:VICTOR
Last Name:DESERPA
Suffix:
Gender:M
Credentials:M ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 SUMMER ST
Mailing Address - Street 2:
Mailing Address - City:EAST BRIDGEWATER
Mailing Address - State:MA
Mailing Address - Zip Code:02333-1053
Mailing Address - Country:US
Mailing Address - Phone:508-580-4154
Mailing Address - Fax:
Practice Address - Street 1:315 SUMMER ST
Practice Address - Street 2:
Practice Address - City:EAST BRIDGEWATER
Practice Address - State:MA
Practice Address - Zip Code:02333-1053
Practice Address - Country:US
Practice Address - Phone:508-580-4154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-17
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA162103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist