Healthcare Provider Details

I. General information

NPI: 1184869174
Provider Name (Legal Business Name): REBECCA LYNN RAYMOND OT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2008
Last Update Date: 12/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 MASONIC AVE
WALLINGFORD CT
06492-3048
US

IV. Provider business mailing address

PO BOX 70
WALLINGFORD CT
06492-7001
US

V. Phone/Fax

Practice location:
  • Phone: 203-679-5900
  • Fax: 203-679-6459
Mailing address:
  • Phone: 203-679-5900
  • Fax: 203-679-6459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License Number283X00000X
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: