Provider Demographics
NPI:1992468086
Name:ROBERT, MARYELLEN (PT)
Entity Type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:
Last Name:ROBERT
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 1:58 ANSON RD
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-5705
Mailing Address - Country:US
Mailing Address - Phone:978-254-7614
Mailing Address - Fax:
Practice Address - Street 1:200 RESERVOIR ST STE 309
Practice Address - Street 2:
Practice Address - City:NEEDHAM HEIGHTS
Practice Address - State:MA
Practice Address - Zip Code:02494-3146
Practice Address - Country:US
Practice Address - Phone:617-302-5015
Practice Address - Fax:617-302-5153
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-15
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9482225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist