Healthcare Provider Details

I. General information

NPI: 1851801146
Provider Name (Legal Business Name): LAURA MARIE ANTONELLI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2017
Last Update Date: 10/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306A HIGH ST
GREENFIELD MA
01301-2611
US

IV. Provider business mailing address

46 FORT SQ
GREENFIELD MA
01301-2822
US

V. Phone/Fax

Practice location:
  • Phone: 413-773-3379
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number22067
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: