Provider Demographics
NPI:1063576353
Name:MACK, BRENDA FRAN (PT)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:FRAN
Last Name:MACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:FRAN
Other - Last Name:NOVICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21 SMITH RD
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545-4568
Mailing Address - Country:US
Mailing Address - Phone:508-792-3908
Mailing Address - Fax:
Practice Address - Street 1:157 UNION ST
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-1228
Practice Address - Country:US
Practice Address - Phone:508-486-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11463225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist