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General NPI Number Information
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NPI Number | 1821743113
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Entity Type | Organization
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Legal Business Name | DYNAMIC CHILD
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Dates
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Enumeration Date | 02/16/2022
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Last Update Date | 02/16/2022
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Provider Practice Location Address
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Address Line | 175 HARTFORD TURNPIKE
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City | TOLLAND
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State | CT
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Zip | 06084
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Country | US
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Telephone | 860-310-8676
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Fax |
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Provider Business Mailing Address
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Address Line | 64 LAMB RD
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City | STAFFORD SPRINGS
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State | CT
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Zip | 06076-3313
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Country | US
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Telephone | 860-310-8676
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MS. REGAN HILLEBRECHT WALTERS
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Credential | COTA/L
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Telephone | 860-310-8676
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225XP0200X
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Taxonomy Name | Pediatric Occupational Therapist
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License Number |
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License Number State |
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