Basic Information
| Provider Information | |||||||||
| NPI: | 1346281565 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | QUIRK | ||||||||
| FirstName: | MICHELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 435 HARTFORD TPKE | ||||||||
| Address2: | SUITE U | ||||||||
| City: | VERNON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060664852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609791611 | ||||||||
| FaxNumber: | 2038663014 | ||||||||
| Practice Location | |||||||||
| Address1: | 145 HAZARD AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | ENFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060824521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602652571 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 01/28/2016 | ||||||||
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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 | 174400000X | 005596 | CT | N | Other Service Providers | Specialist | 225100000X | 005596 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 004167278 | 05 | CT | MEDICAID | 080005596CT27 | 01 | CT | BCBS | OTHER |