Provider Demographics
NPI:1710381942
Name:DEMELLO, MARY (PTA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:DEMELLO
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 1:4 ANDYS CT
Mailing Address - Street 2:
Mailing Address - City:ACUSHNET
Mailing Address - State:MA
Mailing Address - Zip Code:02743-1209
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 ANDYS CT
Practice Address - Street 2:
Practice Address - City:ACUSHNET
Practice Address - State:MA
Practice Address - Zip Code:02743-1209
Practice Address - Country:US
Practice Address - Phone:774-644-2753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-17
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2451225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant