Provider Demographics
NPI:1851865950
Name:MANDUCA, MARY LYNN (DPT)
Entity Type:Individual
Prefix:
First Name:MARY LYNN
Middle Name:
Last Name:MANDUCA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:411 MASS AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-3739
Mailing Address - Country:US
Mailing Address - Phone:978-263-0007
Mailing Address - Fax:978-263-0014
Practice Address - Street 1:29 HUDSON RD
Practice Address - Street 2:
Practice Address - City:SUDBURY
Practice Address - State:MA
Practice Address - Zip Code:01776-1757
Practice Address - Country:US
Practice Address - Phone:978-579-0009
Practice Address - Fax:978-579-0018
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA24003225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist