Basic Information
| Provider Information | |||||||||
| NPI: | 1255311411 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NEVINS | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | LAURA KELLEHER | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26 MIDDLEBURY LANE | ||||||||
| Address2: | |||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019153433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789270907 | ||||||||
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| Practice Location | |||||||||
| Address1: | 26 MIDDLEBURY LN | ||||||||
| Address2: | |||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019151300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789270907 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2006 | ||||||||
| LastUpdateDate: | 09/17/2008 | ||||||||
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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 | 13033 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0705373 | 05 | MA | MEDICAID |