=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790592608
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TATIANA MIHAITA CTRS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2024
-----------------------------------------------------
Last Update Date | 12/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 940 BELMONT ST BLDG 23
-----------------------------------------------------
City | BROCKTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02301-5568
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 774-465-0890
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 940 BELMONT ST MAIL CODE BR135
-----------------------------------------------------
City | BROCKTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225800000X
-----------------------------------------------------
Taxonomy Name | Recreation Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------