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NPI Code Detail

MEDICARE: MS. BRENDA LEE MACPHERSON ATC, LAT

MEDICARE: MS. BRENDA LEE MACPHERSON ATC, LAT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12255A2300XAthletic TrainerAT1102MA

General Provider Information

NPI Number : 1619932852
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. BRENDA LEE MACPHERSON ATC, LAT
Provider Business Mailing Address
First Line : 210 WASHINGTON ST
Second Line :
City : PEABODY
State : MA
Zip : 01960-5441
Country : US
Telephone Number : 978-532-4712
Fax Number :
Provider Business Practice Location Address
First Line : 103 GARLAND ST
Second Line :
City : EVERETT
State : MA
Zip : 02149-5066
Country : US
Telephone Number : 617-381-7175
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/19/2006
Last Update Date : 07/08/2007

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