Basic Information
| Provider Information | |||||||||
| NPI: | 1720287790 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHELAN | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 PARKER HILL AVE | ||||||||
| Address2: | |||||||||
| City: | ROXBURY CROSSING | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021202847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177545800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 125 PARKER HILL AVE | ||||||||
| Address2: | |||||||||
| City: | ROXBURY CROSSING | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021202847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177545800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2007 | ||||||||
| LastUpdateDate: | 07/11/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 8561 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.