Provider Demographics
NPI:1437343324
Name:MAZARES, MELANIE
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:MAZARES
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 1:1565 MAIN ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:TEWKSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01876-2085
Mailing Address - Country:US
Mailing Address - Phone:978-851-8768
Mailing Address - Fax:978-851-8606
Practice Address - Street 1:67 PARKHURST RD
Practice Address - Street 2:
Practice Address - City:CHELMSFORD
Practice Address - State:MA
Practice Address - Zip Code:01824-1518
Practice Address - Country:US
Practice Address - Phone:978-441-9452
Practice Address - Fax:978-454-9292
Is Sole Proprietor?:No
Enumeration Date:2007-09-04
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA15564225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0717932Medicaid
MA0717932Medicaid