Healthcare Provider Details

I. General information

NPI: 1053431221
Provider Name (Legal Business Name): GLENELL MORRIS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 06/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 LITCHFIELD ST
TORRINGTON CT
06790-6679
US

IV. Provider business mailing address

540 LITCHFIELD ST
TORRINGTON CT
06790-6679
US

V. Phone/Fax

Practice location:
  • Phone: 860-496-6666
  • Fax: 860-496-6753
Mailing address:
  • Phone: 860-496-6666
  • Fax: 860-496-6753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3829
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: