Provider Demographics
NPI:1720309081
Name:DEFOSSE, MICHAEL (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DEFOSSE
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 171599
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02117-3438
Mailing Address - Country:US
Mailing Address - Phone:617-699-3527
Mailing Address - Fax:
Practice Address - Street 1:444 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-1046
Practice Address - Country:US
Practice Address - Phone:781-937-9777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-21
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8852225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist