=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619486073
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATTYA JEAN GANJANATHAVAT LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2017
-----------------------------------------------------
Last Update Date | 09/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 163 BROAD ST
-----------------------------------------------------
City | MILFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06460-4726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-513-9594
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 303R ISINGLASS RD
-----------------------------------------------------
City | SHELTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06484-5708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-613-0731
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 9711
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------