Basic Information
| Provider Information | |||||||||
| NPI: | 1083184519 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIRUSSO | ||||||||
| FirstName: | TRACEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BURKE | ||||||||
| OtherFirstName: | TRACEY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3 GROVELAND RD | ||||||||
| Address2: | |||||||||
| City: | MELROSE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021765118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179433797 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 127 CAMBRIDGE ST STE 2B | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018033735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7812722536 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2018 | ||||||||
| LastUpdateDate: | 12/07/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 9928 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.