Healthcare Provider Details

I. General information

NPI: 1205219060
Provider Name (Legal Business Name): TRADING SPACES ABA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2015
Last Update Date: 03/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

437 NAUBUC AVE STE. 105
GLASTONBURY CT
06033-1080
US

IV. Provider business mailing address

2800 MAIN STREET
GLASTONBURY CT
06033-1080
US

V. Phone/Fax

Practice location:
  • Phone: 321-914-7430
  • Fax: 660-812-2399
Mailing address:
  • Phone: 860-430-1340
  • Fax: 860-812-2399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. GLENROY PATRICK PATTERSON
Title or Position: CEO
Credential:
Phone: 860-430-1340