Healthcare Provider Details

I. General information

NPI: 1164676862
Provider Name (Legal Business Name): KEONA REYES OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2008
Last Update Date: 11/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 N PLAINS INDUSTRIAL RD BLDG 2
WALLINGFORD CT
06492-2360
US

IV. Provider business mailing address

203 BROAD ST UNIT 2C
MILFORD CT
06460-4750
US

V. Phone/Fax

Practice location:
  • Phone: 203-949-9337
  • Fax: 203-284-3779
Mailing address:
  • Phone: 203-876-2000
  • Fax: 203-876-1545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number002887
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: