Provider Demographics
NPI:1629549480
Name:MODISETTE, MORA (PT)
Entity type:Individual
Prefix:
First Name:MORA
Middle Name:
Last Name:MODISETTE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MORA
Other - Middle Name:
Other - Last Name:OMALLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1079 COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-1016
Mailing Address - Country:US
Mailing Address - Phone:617-536-1161
Mailing Address - Fax:
Practice Address - Street 1:1079 COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-1016
Practice Address - Country:US
Practice Address - Phone:617-536-1161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-05
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA021599225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist