=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144805078
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOMEWHERE OVER THE SPECTRUM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2021
-----------------------------------------------------
Last Update Date | 09/10/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 WEBSTER SQUARE RD BLDG 1
-----------------------------------------------------
City | BERLIN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06037-2329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-420-3800
-----------------------------------------------------
Fax | 860-420-3801
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120 WEBSTER SQUARE RD BLDG 1
-----------------------------------------------------
City | BERLIN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06037-2329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-420-3800
-----------------------------------------------------
Fax | 860-420-3801
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | COURTNEY WELCH
-----------------------------------------------------
Credential | MBA
-----------------------------------------------------
Telephone | 860-420-3800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------