=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871240515
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE MARIE HAUDEGAND-GOUGH OT/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2022
-----------------------------------------------------
Last Update Date | 03/02/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 160 SIMSBURY RD
-----------------------------------------------------
City | WEST HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06117-1469
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-523-3808
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 551 FOSTER ST
-----------------------------------------------------
City | SOUTH WINDSOR
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06074-2936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-812-5653
-----------------------------------------------------
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 | 001925
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------