Basic Information
| Provider Information | |||||||||
| NPI: | 1598715054 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRASSO | ||||||||
| FirstName: | MICHELE | ||||||||
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| Credential: | RPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 619 | ||||||||
| Address2: | |||||||||
| City: | HIGGANUM | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064410619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603452622 | ||||||||
| FaxNumber: | 8603452626 | ||||||||
| Practice Location | |||||||||
| Address1: | 3A CANDLEWOOD HILL ROAD | ||||||||
| Address2: | |||||||||
| City: | HIGGANUM | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064414202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603452622 | ||||||||
| FaxNumber: | 8603452626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 10/05/2015 | ||||||||
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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 | 004600 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 080004600CT03 | 01 | CT | ANTHEM BC/BS | OTHER | 004145480 | 05 | CT | MEDICAID | 5360125 | 01 | CT | AETNA | OTHER | 68562 | 01 | CT | OXFORD/ORTHONET | OTHER | 15701 | 01 | CT | CIGNA/ORTHONET | OTHER |