=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669743910
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. DYAN V COMBES
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2012
-----------------------------------------------------
Last Update Date | 01/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19 CONSTITUTION WAY
-----------------------------------------------------
City | LITCHFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06759-3428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-567-9500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 99 NALETTE DR
-----------------------------------------------------
City | WINSTED
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06098-1859
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-379-3763
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 2776
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------