Provider Demographics
NPI:1407515091
Name:TIGHE, MARYELLEN LEE
Entity Type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:LEE
Last Name:TIGHE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 OLD LIVERPOOL RD STE 2
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-6033
Mailing Address - Country:US
Mailing Address - Phone:315-218-1451
Mailing Address - Fax:315-451-1752
Practice Address - Street 1:604 OLD LIVERPOOL RD STE 2
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-6033
Practice Address - Country:US
Practice Address - Phone:315-218-1451
Practice Address - Fax:315-451-1752
Is Sole Proprietor?:No
Enumeration Date:2021-12-11
Last Update Date:2021-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048331225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist