Basic Information
| Provider Information | |||||||||
| NPI: | 1245669845 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALLORAN | ||||||||
| FirstName: | MARYELLEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BLANCO | ||||||||
| OtherFirstName: | MARYELLEN | ||||||||
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| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1 CREDIT UNION WAY FL 3 | ||||||||
| Address2: | |||||||||
| City: | RANDOLPH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023684633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7819613370 | ||||||||
| FaxNumber: | 7819611291 | ||||||||
| Practice Location | |||||||||
| Address1: | 360 WEST ST STE 110 | ||||||||
| Address2: | |||||||||
| City: | PITTSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273129448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195335390 | ||||||||
| FaxNumber: | 9195335255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2013 | ||||||||
| LastUpdateDate: | 10/27/2017 | ||||||||
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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 | P17521 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.