Provider Demographics
NPI:1427323625
Name:DEISROTH-KIM, MOLLY (MS)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:DEISROTH-KIM
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 GREEN WAY
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01778-2626
Mailing Address - Country:US
Mailing Address - Phone:508-358-4435
Mailing Address - Fax:
Practice Address - Street 1:40 2ND AVE
Practice Address - Street 2:SUITE 510
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1132
Practice Address - Country:US
Practice Address - Phone:781-487-6103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-20
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN127683224Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Y00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersClinical Exercise Physiologist