Provider Demographics
NPI:1831249879
Name:SOARES, MARY E (LIC AC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:SOARES
Suffix:
Gender:F
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 HARBOR ROAD
Mailing Address - Street 2:
Mailing Address - City:MATTAPOISETT
Mailing Address - State:MA
Mailing Address - Zip Code:02739
Mailing Address - Country:US
Mailing Address - Phone:508-758-6434
Mailing Address - Fax:
Practice Address - Street 1:WATERCOURSE CENTER
Practice Address - Street 2:21 HARBOR ROAD
Practice Address - City:MATTAPOISETT
Practice Address - State:MA
Practice Address - Zip Code:02739
Practice Address - Country:US
Practice Address - Phone:508-758-6434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA630171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist