Basic Information
| Provider Information | |||||||||
| NPI: | 1073569455 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLLETTE | ||||||||
| FirstName: | NATHAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2408 WHITNEY AVE | ||||||||
| Address2: | PO BOX 5576 | ||||||||
| City: | HAMDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065183209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2034073500 | ||||||||
| FaxNumber: | 2032811164 | ||||||||
| Practice Location | |||||||||
| Address1: | 258 BROAD ST | ||||||||
| Address2: | |||||||||
| City: | MILFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064603226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038825632 | ||||||||
| FaxNumber: | 2038827200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 09/18/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 005875 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 080005875CT03 | 01 | CT | ANTHEM BCBS | OTHER |