Basic Information
| Provider Information | |||||||||
| NPI: | 1790126175 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORALES | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | JANNETT | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 29 DIETZ RD | ||||||||
| Address2: | |||||||||
| City: | HYDE PARK | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021361132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173352116 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4593 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | ROSLINDALE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021314844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173279097 | ||||||||
| FaxNumber: | 6173274307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2013 | ||||||||
| LastUpdateDate: | 07/12/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 7921 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.