Provider Demographics
NPI:1225201056
Name:DAVILUS, EMMANUELLA (PTA)
Entity Type:Individual
Prefix:MS
First Name:EMMANUELLA
Middle Name:
Last Name:DAVILUS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 RESERVOIR ST
Mailing Address - Street 2:#212
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-1166
Mailing Address - Country:US
Mailing Address - Phone:617-792-9497
Mailing Address - Fax:
Practice Address - Street 1:40 RESERVOIR ST
Practice Address - Street 2:#212
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1166
Practice Address - Country:US
Practice Address - Phone:617-792-9497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-13
Last Update Date:2008-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8054225200000X
225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant