Basic Information
| Provider Information | |||||||||
| NPI: | 1225017221 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIBONA | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SCOZZAFAVA | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | LEE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 69 SAND PIT RD | ||||||||
| Address2: | STE 201 | ||||||||
| City: | DANBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037485631 | ||||||||
| FaxNumber: | 2032073194 | ||||||||
| Practice Location | |||||||||
| Address1: | 69 SAND PIT RD | ||||||||
| Address2: | STE 201 | ||||||||
| City: | DANBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068104004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037485631 | ||||||||
| FaxNumber: | 2032073194 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | X | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 6513 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 080006513CT05 | 01 | CT | BLUE CROSS BLUE SHIELD | OTHER | 3783796 | 01 | CT | AETNA | OTHER |