Healthcare Provider Details

I. General information

NPI: 1821441577
Provider Name (Legal Business Name): EDWARD DECHELLIS JR. PTA, MT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2016
Last Update Date: 07/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 OLD WENDELL RD
NORTHFIELD MA
01360-9674
US

IV. Provider business mailing address

233 OLD WENDELL RD
NORTHFIELD MA
01360-9674
US

V. Phone/Fax

Practice location:
  • Phone: 413-218-6715
  • Fax:
Mailing address:
  • Phone: 413-218-6715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number3729
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number6291
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: