Basic Information
Provider Information | |||||||||
NPI: | 1821194838 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TRIVERI | ||||||||
FirstName: | KYLA | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DONNELLY | ||||||||
OtherFirstName: | KYLA | ||||||||
OtherMiddleName: | A | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MSPT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 250 EAST MAIN ST | ||||||||
Address2: |   | ||||||||
City: | NORTON | ||||||||
State: | MA | ||||||||
PostalCode: | 027662436 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5082854155 | ||||||||
FaxNumber: | 5082854483 | ||||||||
Practice Location | |||||||||
Address1: | 99 VANDERBILT AVE | ||||||||
Address2: |   | ||||||||
City: | NORWOOD | ||||||||
State: | MA | ||||||||
PostalCode: | 020625011 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7813525400 | ||||||||
FaxNumber: | 5082854483 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/16/2006 | ||||||||
LastUpdateDate: | 03/13/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 16578 | MA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | Y68372 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER | 470237 | 01 | MA | TUFTS | OTHER |