Provider Demographics
NPI:1295897833
Name:DEROSIER, MICHAEL R (ATC)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:R
Last Name:DEROSIER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1892 CHRISTIAN ST
Mailing Address - Street 2:
Mailing Address - City:WHITE RIVER JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05001-5402
Mailing Address - Country:US
Mailing Address - Phone:802-295-1934
Mailing Address - Fax:603-646-9941
Practice Address - Street 1:DARTMOUTH COLLEGE
Practice Address - Street 2:ALUMNI GYMNASIUM, HB 6083
Practice Address - City:HANOVER
Practice Address - State:NH
Practice Address - Zip Code:03755
Practice Address - Country:US
Practice Address - Phone:603-646-9772
Practice Address - Fax:603-646-9941
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT000605002255A2300X
NH03602255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer