Provider Demographics
NPI:1609232636
Name:BLY, JONATHAN ALLEN (PTA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ALLEN
Last Name:BLY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 MOSGROVE AVE
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-1113
Mailing Address - Country:US
Mailing Address - Phone:617-401-5892
Mailing Address - Fax:
Practice Address - Street 1:15 MOSGROVE AVE
Practice Address - Street 2:
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131-1113
Practice Address - Country:US
Practice Address - Phone:617-401-5892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-06
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9047174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist