Provider Demographics
NPI:1376562504
Name:DETORE, CHRISTINE AMARAL (DPT)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:AMARAL
Last Name:DETORE
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 1:40 N MAIN ST
Mailing Address - Street 2:C O ACTIVE PHYSICAL THERAPY
Mailing Address - City:BELLINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02019
Mailing Address - Country:US
Mailing Address - Phone:508-966-2717
Mailing Address - Fax:508-966-2095
Practice Address - Street 1:40 N MAIN ST
Practice Address - Street 2:C O ACTIVE PHYSICAL THERAPY
Practice Address - City:BELLINGHAM
Practice Address - State:MA
Practice Address - Zip Code:02019
Practice Address - Country:US
Practice Address - Phone:508-966-2717
Practice Address - Fax:508-966-2095
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16936225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AMY69512Medicare ID - Type Unspecified