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General NPI Number Information
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NPI Number | 1154506152
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Entity Type | Individual
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Provider Name | SABRENA DIANA LARY ATC
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Gender | Female
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Dates
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Enumeration Date | 01/08/2008
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Last Update Date | 03/23/2020
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Provider Practice Location Address
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Address Line | 330 WESTERN BLVD STE 101
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City | GLASTONBURY
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State | CT
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Zip | 06033-4383
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Country | US
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Telephone | 860-657-4723
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Fax |
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Provider Business Mailing Address
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Address Line | 30 BABULA RD
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City | THOMPSON
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State | CT
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Zip | 06277-1401
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Country | US
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Telephone | 860-208-8611
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 0334
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License Number State | NH
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 1625
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License Number State | MA
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Taxonomy #3
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 2009003225
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License Number State | MO
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Taxonomy #4
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 000438
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License Number State | CT
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