Provider Demographics
NPI:1063729796
Name:DIEDRICKSEN, ELLIZABETH ANN
Entity type:Individual
Prefix:
First Name:ELLIZABETH
Middle Name:ANN
Last Name:DIEDRICKSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 BRADFORD ST
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02072-2874
Mailing Address - Country:US
Mailing Address - Phone:781-344-1364
Mailing Address - Fax:
Practice Address - Street 1:31 BRADFORD ST
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:MA
Practice Address - Zip Code:02072-2874
Practice Address - Country:US
Practice Address - Phone:781-344-1364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-01
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7556225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics