Provider Demographics
NPI:1508376831
Name:MACKAY, TAMA C (LMT, ART, CKTP)
Entity Type:Individual
Prefix:
First Name:TAMA
Middle Name:C
Last Name:MACKAY
Suffix:
Gender:F
Credentials:LMT, ART, CKTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 BERKELEY TER
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-4919
Mailing Address - Country:US
Mailing Address - Phone:203-747-4485
Mailing Address - Fax:
Practice Address - Street 1:23 RADIO PL
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06906-2219
Practice Address - Country:US
Practice Address - Phone:203-998-5826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-29
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT008668225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist