Healthcare Provider Details

I. General information

NPI: 1073714945
Provider Name (Legal Business Name): MARY LOUISE VOLANTH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 GOVERNORS AVE
MEDFORD MA
02155-1644
US

IV. Provider business mailing address

5 BELMONT SQ UNIT #1
SOMERVILLE MA
02143-2505
US

V. Phone/Fax

Practice location:
  • Phone: 781-391-5400
  • Fax: 781-396-0649
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberAH5588-OT
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: