Healthcare Provider Details

I. General information

NPI: 1720114929
Provider Name (Legal Business Name): JULIE A HANNON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 CAMBRIDGE ST
BOSTON MA
02114-2743
US

IV. Provider business mailing address

8 LAKESIDE DR
SHREWSBURY MA
01545-4539
US

V. Phone/Fax

Practice location:
  • Phone: 617-643-9999
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number6233
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: