=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730410689
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THERESA A GATELY FAMILY PARTNER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2010
-----------------------------------------------------
Last Update Date | 01/15/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4121 WASHINGTON ST
-----------------------------------------------------
City | ROSLINDALE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02131-1714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 857-939-1190
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4121 WASHINGTON ST
-----------------------------------------------------
City | ROSLINDALE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02131-1714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 857-939-1190
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172V00000X
-----------------------------------------------------
Taxonomy Name | Community Health Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------