=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144399866
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETER W. CATUCCIO ATC, LAT,PTA, CSCS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 140 LORELEI CT
-----------------------------------------------------
City | SOUTHBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06488-2733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-264-0435
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 140 LORELEI CT
-----------------------------------------------------
City | SOUTHBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06488-2733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-264-0435
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 000146
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------