Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 02331 | RI |
N | 2251S0007X | Physical Therapist - Sports |
NPI | 1215244744 |
---|---|
Provider Name | Diane M Macksoud |
First Address | Providence, RI 02908-5794 |
Second Address | Providence, RI 02908-5794 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/09/2010 |
Last Update Date | 03/09/2010 |