Healthcare Provider Details

I. General information

NPI: 1497870935
Provider Name (Legal Business Name): MAUREEN CLARE REYNOLDS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 COOPER ST
AGAWAM MA
01001
US

IV. Provider business mailing address

46 MAPLE ST # 2
CHICOPEE MA
01020-2627
US

V. Phone/Fax

Practice location:
  • Phone: 413-786-8000
  • Fax: 413-789-2359
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2058
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: