Provider Demographics
NPI:1295121911
Name:DESEPEDA, MAUREEN DIJAMCO (PT)
Entity type:Individual
Prefix:
First Name:MAUREEN
Middle Name:DIJAMCO
Last Name:DESEPEDA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MAUREEN
Other - Middle Name:VILLAHERMOSA
Other - Last Name:DIJAMCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:4052 75TH ST
Mailing Address - Street 2:APT. 6G
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1051
Mailing Address - Country:US
Mailing Address - Phone:929-235-6081
Mailing Address - Fax:
Practice Address - Street 1:4052 75TH ST
Practice Address - Street 2:APT. 6G
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1051
Practice Address - Country:US
Practice Address - Phone:929-235-6081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-09
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034334225100000X
NJ40QA01575100225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist