Provider Demographics
NPI:1689987257
Name:DESIR, JEAN RICHARD
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:RICHARD
Last Name:DESIR
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 1:3222 ARBOR DR
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545-6010
Mailing Address - Country:US
Mailing Address - Phone:774-275-9115
Mailing Address - Fax:
Practice Address - Street 1:51 UNION ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1194
Practice Address - Country:US
Practice Address - Phone:508-756-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-23
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA95273201OtherNETWORK
MA1487863494OtherMMIS
MA1894196OtherMBHP
MA1081860OtherFALLON/BEACON
MA1894196Medicaid