Healthcare Provider Details

I. General information

NPI: 1093903296
Provider Name (Legal Business Name): MARY J BUCKO P.T.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2007
Last Update Date: 10/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 LYNNFIELD ST
LYNN MA
01904-1424
US

IV. Provider business mailing address

19 EVERETT ST
LYNN MA
01904-2811
US

V. Phone/Fax

Practice location:
  • Phone: 781-477-3033
  • Fax:
Mailing address:
  • Phone: 781-581-1716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number288
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: