Provider Demographics
NPI:1821233008
Name:DESROCHES, PETER M (PTA)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:M
Last Name:DESROCHES
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 W LEA BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19802-2500
Mailing Address - Country:US
Mailing Address - Phone:302-765-4464
Mailing Address - Fax:
Practice Address - Street 1:700 W LEA BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19802-2500
Practice Address - Country:US
Practice Address - Phone:302-765-4464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-02
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ2-0000238225200000X
PATE007800225200000X
CAAT 8374225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant