Healthcare Provider Details

I. General information

NPI: 1427061274
Provider Name (Legal Business Name): MARYELLEN MAYNES PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 N MEADOWS RD
MEDFIELD MA
02052-2317
US

IV. Provider business mailing address

372 CHAMBERLAIN ST
HOLLISTON MA
01746-1529
US

V. Phone/Fax

Practice location:
  • Phone: 508-359-9119
  • Fax: 508-359-9115
Mailing address:
  • Phone: 508-429-4787
  • Fax: 508-429-1698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT5363
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: