Healthcare Provider Details

I. General information

NPI: 1316547201
Provider Name (Legal Business Name): MICHELLE JANE MAILLOUX PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2020
Last Update Date: 10/29/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

484 MAIN ST STE 600
WORCESTER MA
01608-1881
US

IV. Provider business mailing address

41 BRIAR AVE
LOWELL MA
01852-1641
US

V. Phone/Fax

Practice location:
  • Phone: 800-244-2756
  • Fax:
Mailing address:
  • Phone: 978-761-5322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number25187
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: