Provider Demographics
NPI:1750399143
Name:LAMALFA, MARY JETTE (PT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JETTE
Last Name:LAMALFA
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 1:512 SAYBROOK RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4788
Mailing Address - Country:US
Mailing Address - Phone:830-343-5997
Mailing Address - Fax:860-343-6042
Practice Address - Street 1:512 SAYBROOK RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-4788
Practice Address - Country:US
Practice Address - Phone:830-343-5997
Practice Address - Fax:860-343-6042
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3325225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT080003325CT14OtherBCBS
CT004111689Medicaid
CT4258766OtherAETNA
491670OtherCIGNA
P4309651OtherOXFORD
761899OtherCONNECTICARE
CTD400039900Medicare PIN