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General NPI Number Information
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NPI Number | 1922129451
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Entity Type | Individual
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Provider Name | MARY ANN DEGRUTTOLA RPT
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Gender | Female
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Dates
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Enumeration Date | 04/02/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 72 SALMON BROOK DR
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City | GLASTONBURY
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State | CT
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Zip | 06033-2131
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Country | US
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Telephone | 860-633-4452
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Fax |
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Provider Business Mailing Address
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Address Line | 26 PEASE LN P.O. BOX 349
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City | SOUTH GLASTONBURY
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State | CT
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Zip | 06073-2015
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Country | US
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Telephone | 860-659-2243
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 591
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License Number State | CT
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