Provider Demographics
NPI:1366481608
Name:FENNELL, DECLAN E (PT)
Entity Type:Individual
Prefix:MR
First Name:DECLAN
Middle Name:E
Last Name:FENNELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 SYCAMORE RD
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-7308
Mailing Address - Country:US
Mailing Address - Phone:617-333-8389
Mailing Address - Fax:
Practice Address - Street 1:16 SYCAMORE RD
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-7308
Practice Address - Country:US
Practice Address - Phone:617-333-8389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
MA13347225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA603413OtherHARVARD PILGRIM
MA102302300OtherACS
MA6440025OtherUNITED HEALTHCARE
MAY67710OtherBLUE CROSS
MA458473OtherTUFTS HEALTH PLAN
MA8211OtherNEIGHBORHOOD HEALTH PLAN