Healthcare Provider Details

I. General information

NPI: 1700160041
Provider Name (Legal Business Name): ANSEL GARVEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2011
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 COLLEGE ST
WORCESTER MA
01610-2322
US

IV. Provider business mailing address

15 WIESER DR
WESTFIELD MA
01085-5130
US

V. Phone/Fax

Practice location:
  • Phone: 508-793-2627
  • Fax: 508-793-3974
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2235
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2000006552
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerBOARD OF CERTIFICATION

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: