MEDICARE: TODD PROVOST PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	007915	MA

General Provider Information

NPI Number	:	1134311962
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TODD PROVOST PTA

Provider Business Mailing Address
First Line	:	40 WOODLAND ST
Second Line	:
City	:	HARTFORD
State	:	CT
Zip	:	06105-2327
Country	:	US
Telephone Number	:	860-522-2717
Fax Number	:	860-249-6164

Provider Business Practice Location Address
First Line	:	673 COTTAGE GROVE RD
Second Line	:
City	:	BLOOMFIELD
State	:	CT
Zip	:	06002-3033
Country	:	US
Telephone Number	:	860-286-1043
Fax Number	:	860-286-2836

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/15/2007
Last Update Date	:	08/15/2007

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Directions to “ TODD PROVOST PTA” Practice Location

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