Healthcare Provider Details

I. General information

NPI: 1598889594
Provider Name (Legal Business Name): TERESA MARTINI DONOVAN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 RUBY AVE
MARBLEHEAD MA
01945-1623
US

IV. Provider business mailing address

12 RUBY AVE
MARBLEHEAD MA
01945-1623
US

V. Phone/Fax

Practice location:
  • Phone: 781-990-3370
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number17483
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: