Provider Demographics
NPI:1447385729
Name:BROSSMANMCINTIRE, ILLONA SUSAN (PT)
Entity Type:Individual
Prefix:
First Name:ILLONA
Middle Name:SUSAN
Last Name:BROSSMANMCINTIRE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 MOWER ST
Mailing Address - Street 2:
Mailing Address - City:PAXTON
Mailing Address - State:MA
Mailing Address - Zip Code:01612-1500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:255 PARK AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-1953
Practice Address - Country:US
Practice Address - Phone:508-755-7272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2009-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT02088225100000X
MA3143225100000X
SC5623225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist