Healthcare Provider Details

I. General information

NPI: 1568162170
Provider Name (Legal Business Name): MASSACHUSETTS PHYSICAL THERAPY SERVICES OF QUINCY BAY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2023
Last Update Date: 04/13/2023
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 BRACKETT ST
QUINCY MA
02169-4647
US

IV. Provider business mailing address

PO BOX 51266
LAFAYETTE LA
70505-1266
US

V. Phone/Fax

Practice location:
  • Phone: 617-934-1079
  • Fax: 617-934-1132
Mailing address:
  • Phone: 337-233-1307
  • Fax: 337-443-4154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: JOSHUA L PROFFITT
Title or Position: PRESIDENT
Credential:
Phone: 337-233-1307