Provider Demographics
NPI:1962182832
Name:MAMEDOV, RUSLAN (MT-BC)
Entity type:Individual
Prefix:
First Name:RUSLAN
Middle Name:
Last Name:MAMEDOV
Suffix:
Gender:M
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 PRESCOTT ST APT 1
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-1713
Mailing Address - Country:US
Mailing Address - Phone:201-888-0155
Mailing Address - Fax:
Practice Address - Street 1:67 S BEDFORD ST STE 101W
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01803-5152
Practice Address - Country:US
Practice Address - Phone:617-865-9445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist