Provider Demographics
NPI:1316628027
Name:DEAMBROSE, MITCHELL (DPT)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:DEAMBROSE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 NEEDHAM ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02464-1595
Mailing Address - Country:US
Mailing Address - Phone:617-641-6700
Mailing Address - Fax:617-663-6032
Practice Address - Street 1:244 NEEDHAM ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02464-1595
Practice Address - Country:US
Practice Address - Phone:617-641-6700
Practice Address - Fax:617-663-6032
Is Sole Proprietor?:No
Enumeration Date:2023-07-26
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPTL26269225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist