Provider Demographics
NPI:1669689956
Name:YACINO, SUSAN JOY (PTA)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:JOY
Last Name:YACINO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 NORMAN LN
Mailing Address - Street 2:
Mailing Address - City:DUDLEY
Mailing Address - State:MA
Mailing Address - Zip Code:01571-5740
Mailing Address - Country:US
Mailing Address - Phone:617-686-5689
Mailing Address - Fax:
Practice Address - Street 1:640 CONCORD AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-1116
Practice Address - Country:US
Practice Address - Phone:617-497-0600
Practice Address - Fax:617-497-4447
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2044225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant