Provider Demographics
NPI:1548717739
Name:FATTALEH, TAMARA (DPT, ATC)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:FATTALEH
Suffix:
Gender:F
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 BRAINTREE HILL OFFICE PARK
Mailing Address - Street 2:STE L02
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-8702
Mailing Address - Country:US
Mailing Address - Phone:781-848-7300
Mailing Address - Fax:781-848-5678
Practice Address - Street 1:25 BRAINTREE HILL OFFICE PARK
Practice Address - Street 2:STE L02
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-8702
Practice Address - Country:US
Practice Address - Phone:781-848-7300
Practice Address - Fax:781-848-5678
Is Sole Proprietor?:No
Enumeration Date:2016-09-06
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA22537225100000X
MA26922255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer