Provider Demographics
NPI:1497176432
Name:DEANGELO, MARC (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:DEANGELO
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 CITATION AVE
Mailing Address - Street 2:
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-1951
Mailing Address - Country:US
Mailing Address - Phone:781-922-0352
Mailing Address - Fax:
Practice Address - Street 1:245 NORTH ST
Practice Address - Street 2:
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-2109
Practice Address - Country:US
Practice Address - Phone:781-922-0352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA23492255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer