Provider Demographics
NPI:1215539309
Name:PROFETTO-IRWIN, MARY F
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:F
Last Name:PROFETTO-IRWIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 BLANKS BLVD
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-1166
Mailing Address - Country:US
Mailing Address - Phone:203-733-0472
Mailing Address - Fax:
Practice Address - Street 1:50 BLANKS BLVD
Practice Address - Street 2:
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437-1166
Practice Address - Country:US
Practice Address - Phone:203-733-0471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001903225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist