Provider Demographics
NPI:1710568142
Name:MASSARELLA, MANDY LEIGH (PT)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:LEIGH
Last Name:MASSARELLA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 ACORN DR
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-2102
Mailing Address - Country:US
Mailing Address - Phone:561-988-2019
Mailing Address - Fax:
Practice Address - Street 1:6343 VIA DE SONRISA DEL SUR
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-8211
Practice Address - Country:US
Practice Address - Phone:561-392-5940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-17
Last Update Date:2021-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT15155225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist