Healthcare Provider Details

I. General information

NPI: 1750163192
Provider Name (Legal Business Name): MICHELLE MARROQUIN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2023
Last Update Date: 10/19/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 CARLON DR
NORTHAMPTON MA
01060-2392
US

IV. Provider business mailing address

17 DRAGON CIR
EASTHAMPTON MA
01027-1301
US

V. Phone/Fax

Practice location:
  • Phone: 413-727-3315
  • Fax: 413-727-3316
Mailing address:
  • Phone: 413-210-2594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number9226
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: