Healthcare Provider Details

I. General information

NPI: 1104333418
Provider Name (Legal Business Name): EWA BLASZCZYK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2018
Last Update Date: 01/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1261 S MAIN ST
PLANTSVILLE CT
06479-1750
US

IV. Provider business mailing address

20 WALKERS XING
SOUTHINGTON CT
06489-2347
US

V. Phone/Fax

Practice location:
  • Phone: 860-628-9000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: