Provider Demographics
NPI:1316755879
Name:MCGILLICUDDY, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MCGILLICUDDY
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 1:129 ASH ST
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02072-3521
Mailing Address - Country:US
Mailing Address - Phone:339-237-8612
Mailing Address - Fax:
Practice Address - Street 1:180 MAIN ST
Practice Address - Street 2:
Practice Address - City:WALPOLE
Practice Address - State:MA
Practice Address - Zip Code:02081-4020
Practice Address - Country:US
Practice Address - Phone:774-203-9071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA15342225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist