Basic Information
| Provider Information | |||||||||
| NPI: | 1346545670 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARTMAN | ||||||||
| FirstName: | LUCILLE | ||||||||
| MiddleName: | WYMER | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WYMER | ||||||||
| OtherFirstName: | CATHERINE | ||||||||
| OtherMiddleName: | LUCILLE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PTA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1775 BOSTON POST ROAD | ||||||||
| Address2: | |||||||||
| City: | OLD SAYBROOK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603996216 | ||||||||
| FaxNumber: | 8603996790 | ||||||||
| Practice Location | |||||||||
| Address1: | 1775 BOSTON POST ROAD | ||||||||
| Address2: | |||||||||
| City: | OLD SAYBROOK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603996216 | ||||||||
| FaxNumber: | 8603996790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2011 | ||||||||
| LastUpdateDate: | 01/18/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172M00000X | 1114 | CT | Y | Other Service Providers | Mechanotherapist | 172M00000X | TEI000164 | PA | N | Other Service Providers | Mechanotherapist | 172M00000X | 2306601364 | VA | N | Other Service Providers | Mechanotherapist |
No ID Information.