Provider Demographics
NPI:1710241088
Name:PROBODY PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:PROBODY PHYSICAL THERAPY, LLC
Other - Org Name:PROBODY PHYSICAL THERAPY, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DPT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:JAAR
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:617-331-3163
Mailing Address - Street 1:265 MEDFORD ST
Mailing Address - Street 2:SUITE 303
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-1963
Mailing Address - Country:US
Mailing Address - Phone:617-331-3163
Mailing Address - Fax:
Practice Address - Street 1:265 MEDFORD ST
Practice Address - Street 2:SUITE 303
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-1963
Practice Address - Country:US
Practice Address - Phone:617-331-3163
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROBODY PHYSICAL THERAPY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-07-01
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16357261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0322377Medicaid
MAJA Y69549OtherMEDICARE PROVIDER IDENIFICATION NUMBER