Healthcare Provider Details

I. General information

NPI: 1861493371
Provider Name (Legal Business Name): ROBERT JOHN WONDOLOWSKI P.T.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 N MAIN ST SUITE 107
NATICK MA
01760-1131
US

IV. Provider business mailing address

163 ALBEE RD
UXBRIDGE MA
01569-1981
US

V. Phone/Fax

Practice location:
  • Phone: 508-650-1856
  • Fax: 508-653-9563
Mailing address:
  • Phone: 508-278-0320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number7571
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: