Provider Demographics
NPI:1972636736
Name:DEROY, THERESA LYDIA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:LYDIA
Last Name:DEROY
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 1:753 NW MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:MA
Mailing Address - Zip Code:01516-2802
Mailing Address - Country:US
Mailing Address - Phone:508-476-1112
Mailing Address - Fax:508-476-2444
Practice Address - Street 1:753 NW MAIN ST
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:MA
Practice Address - Zip Code:01516-2802
Practice Address - Country:US
Practice Address - Phone:508-476-1112
Practice Address - Fax:508-476-2444
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA175554163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0708119Medicaid