Provider Demographics
NPI:1235507872
Name:MAMOS, MICHELLE E (DPT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:E
Last Name:MAMOS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 VERONA ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01904-2041
Mailing Address - Country:US
Mailing Address - Phone:781-913-3105
Mailing Address - Fax:
Practice Address - Street 1:607 NORTH AVE
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01880-1322
Practice Address - Country:US
Practice Address - Phone:781-587-0776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-14
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA219072251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic