Healthcare Provider Details

I. General information

NPI: 1992668982
Provider Name (Legal Business Name): MARY MANDICO KEALEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2025
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 LEGION MEMORIAL DR
CHINA ME
04358-5641
US

IV. Provider business mailing address

22 WILLETTE DR
CHINA ME
04358-4036
US

V. Phone/Fax

Practice location:
  • Phone: 727-385-7547
  • Fax:
Mailing address:
  • Phone: 727-385-7547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT8125
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: