Provider Demographics
NPI:1083974745
Name:LAVELLE, MARY ALICE (LCMT)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ALICE
Last Name:LAVELLE
Suffix:
Gender:F
Credentials:LCMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 MERAIUM AVE, TWIN CITY PLAZA
Mailing Address - Street 2:UNIT 125
Mailing Address - City:LEAMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453
Mailing Address - Country:US
Mailing Address - Phone:978-537-4126
Mailing Address - Fax:
Practice Address - Street 1:875 MERAIUM AVE, TWIN CITY PLAZA
Practice Address - Street 2:UNIT 125
Practice Address - City:LEAMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453
Practice Address - Country:US
Practice Address - Phone:978-537-4126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-29
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9034225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist