Provider Demographics
NPI:1790834935
Name:VINCELLO, LAURIE A (MAPT)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:A
Last Name:VINCELLO
Suffix:
Gender:F
Credentials:MAPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 WINTER ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-1433
Mailing Address - Country:US
Mailing Address - Phone:781-890-9779
Mailing Address - Fax:781-890-5775
Practice Address - Street 1:235 LITTLETON RD
Practice Address - Street 2:
Practice Address - City:WESTFORD
Practice Address - State:MA
Practice Address - Zip Code:01886-3593
Practice Address - Country:US
Practice Address - Phone:978-392-0483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7346225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY69524Medicare ID - Type Unspecified