Healthcare Provider Details

I. General information

NPI: 1801538368
Provider Name (Legal Business Name): SARA ELIZABETH MACDONOUGH-CIVITELLO ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2022
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 MOUNT CARMEL AVE
HAMDEN CT
06518-1908
US

IV. Provider business mailing address

275 MOUNT CARMEL AVE
HAMDEN CT
06518-1908
US

V. Phone/Fax

Practice location:
  • Phone: 203-582-8941
  • Fax:
Mailing address:
  • Phone: 203-582-8941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number000629
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: