Provider Demographics
NPI:1619375698
Name:CONWAY, CECILY (PTA)
Entity Type:Individual
Prefix:
First Name:CECILY
Middle Name:
Last Name:CONWAY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 BUCK ISLAND RD APT K2
Mailing Address - Street 2:
Mailing Address - City:WEST YARMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02673-3368
Mailing Address - Country:US
Mailing Address - Phone:774-208-8101
Mailing Address - Fax:
Practice Address - Street 1:441 BUCK ISLAND RD
Practice Address - Street 2:UNIT K2
Practice Address - City:WEST YARMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02673-3362
Practice Address - Country:US
Practice Address - Phone:774-208-8101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-08
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3192225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant