=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306963764
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. KELLY ECSEDY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22 TOMPKINS ST
-----------------------------------------------------
City | WATERBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06708-1417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-419-0381
-----------------------------------------------------
Fax | 203-419-0389
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 254 TRIANGLE BLVD
-----------------------------------------------------
City | MIDDLEBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06762-3331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-598-7546
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | 000643
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------