Provider Demographics
NPI:1669586160
Name:MACCHELLO, LAURA J (PT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:J
Last Name:MACCHELLO
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 1:1614 HIDDEN LN
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99501-4918
Mailing Address - Country:US
Mailing Address - Phone:907-561-2260
Mailing Address - Fax:907-561-0448
Practice Address - Street 1:701 SESAME ST STE 101
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-6647
Practice Address - Country:US
Practice Address - Phone:907-561-2260
Practice Address - Fax:907-561-0448
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA798225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPT0949Medicaid