Provider Demographics
NPI:1386710820
Name:MAIETTA, ANTHONY (MSPT)
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:
Last Name:MAIETTA
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 RICHARD EGER DR
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01040-9774
Mailing Address - Country:US
Mailing Address - Phone:860-648-0659
Mailing Address - Fax:
Practice Address - Street 1:1477 PARK ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-2235
Practice Address - Country:US
Practice Address - Phone:860-648-0659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007875225100000X
MA17851225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist