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General NPI Number Information
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NPI Number | 1255584561
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Entity Type | Individual
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Provider Name | AMY PROVENCAL PTA
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Gender | Female
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Dates
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Enumeration Date | 10/30/2008
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Last Update Date | 10/30/2008
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Provider Practice Location Address
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Address Line | 950 CAMPBELL AVE
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City | WEST HAVEN
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State | CT
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Zip | 06516-2770
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Country | US
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Telephone | 203-935-5711
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Fax |
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Provider Business Mailing Address
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Address Line | 139 CHARTER OAK AVE
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City | EAST HAVEN
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State | CT
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Zip | 06512-2704
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Country | US
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Telephone | 203-467-1974
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 000199
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License Number State | CT
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