Provider Demographics
NPI:1518626951
Name:MACNEILL, JOHNATHON
Entity Type:Individual
Prefix:
First Name:JOHNATHON
Middle Name:
Last Name:MACNEILL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 BROADWAY APT 2F
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-2054
Mailing Address - Country:US
Mailing Address - Phone:857-221-6282
Mailing Address - Fax:
Practice Address - Street 1:628 BROADWAY APT 2F
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-2054
Practice Address - Country:US
Practice Address - Phone:857-221-6282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1922174226222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist