Provider Demographics
NPI:1679222335
Name:DESIMONE, BRIAN ROBERT
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:ROBERT
Last Name:DESIMONE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 DELWAY RD
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-5206
Mailing Address - Country:US
Mailing Address - Phone:401-578-9616
Mailing Address - Fax:
Practice Address - Street 1:333 GREEN END AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:RI
Practice Address - Zip Code:02842-5620
Practice Address - Country:US
Practice Address - Phone:401-849-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-21
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIOTA01125224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant