Provider Demographics
NPI:1487298030
Name:O'MALLEY, RYAN (PTA)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:O'MALLEY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 IAN KEATS DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02048-3252
Mailing Address - Country:US
Mailing Address - Phone:774-266-6697
Mailing Address - Fax:
Practice Address - Street 1:615 HEATH ST
Practice Address - Street 2:
Practice Address - City:CHESTNUT HILL
Practice Address - State:MA
Practice Address - Zip Code:02467-2160
Practice Address - Country:US
Practice Address - Phone:617-243-9990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-06
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9723225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant