Basic Information
| Provider Information | |||||||||
| NPI: | 1295007029 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'BRIEN | ||||||||
| FirstName: | TRACI | ||||||||
| MiddleName: | |||||||||
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| Credential: | DPT | ||||||||
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| OtherLastName: | RIVIERE | ||||||||
| OtherFirstName: | TRACI | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 47 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WEST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061071926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604094595 | ||||||||
| FaxNumber: | 8604094595 | ||||||||
| Practice Location | |||||||||
| Address1: | 635 BROAD ST | ||||||||
| Address2: | |||||||||
| City: | NEW LONDON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063202543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604478558 | ||||||||
| FaxNumber: | 8604474552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2012 | ||||||||
| LastUpdateDate: | 02/02/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 9300 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.