Basic Information
| Provider Information | |||||||||
| NPI: | 1316534142 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | GARRETT | ||||||||
| FirstName: | LAUREL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 655 TALCOTTVILLE RD APT 54 | ||||||||
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| City: | VERNON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060662335 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 EMERSON DR | ||||||||
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| City: | WINDSOR | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060953204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606886443 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2020 | ||||||||
| LastUpdateDate: | 12/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 44090900 | 05 | CT | MEDICAID |