Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0200X | Occupational Therapist - Pediatrics | 7556 | MA |
NPI | 1063729796 |
---|---|
Provider Name | Ellizabeth Ann Diedricksen |
First Address | Stoughton, MA 02072-2874 |
Second Address | Stoughton, MA 02072-2874 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/09/2010 |
Last Update Date | 01/09/2010 |