Provider Demographics
NPI:1679917223
Name:SOOHOO, DEREK (LMT MMP)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:
Last Name:SOOHOO
Suffix:
Gender:M
Credentials:LMT MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 DAVIS RD
Mailing Address - Street 2:
Mailing Address - City:CHELMSFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01824-1302
Mailing Address - Country:US
Mailing Address - Phone:978-376-3899
Mailing Address - Fax:
Practice Address - Street 1:250 JACKSON ST
Practice Address - Street 2:4TH FLOOR
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-2106
Practice Address - Country:US
Practice Address - Phone:978-376-3899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-25
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
7392225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist