Provider Demographics
NPI:1710354048
Name:MANDARA, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:MANDARA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:354 W BOYLSTON ST
Mailing Address - Street 2:SUITE 111
Mailing Address - City:WEST BOYLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:01583-2373
Mailing Address - Country:US
Mailing Address - Phone:508-852-3700
Mailing Address - Fax:508-852-3777
Practice Address - Street 1:354 W BOYLSTON ST
Practice Address - Street 2:SUITE 111
Practice Address - City:WEST BOYLSTON
Practice Address - State:MA
Practice Address - Zip Code:01583-2373
Practice Address - Country:US
Practice Address - Phone:508-852-3700
Practice Address - Fax:508-852-3777
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-21
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21826225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist