Basic Information
Provider Information | |||||||||
NPI: | 1821454166 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DEPARTMENT OF VETERANS AFFAIRS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 58 PATTERSON LN | ||||||||
Address2: |   | ||||||||
City: | NEWINGTON | ||||||||
State: | NH | ||||||||
PostalCode: | 038012806 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 950 CAMPBELL AVE | ||||||||
Address2: |   | ||||||||
City: | WEST HAVEN | ||||||||
State: | CT | ||||||||
PostalCode: | 065162770 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2039325711 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/31/2015 | ||||||||
LastUpdateDate: | 12/31/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ANTON | ||||||||
AuthorizedOfficialFirstName: | CASSANDRA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | REGISTERED OCCUPATIONAL THERAPIST | ||||||||
AuthorizedOfficialTelephone: | 2036878792 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283X00000X | 11362 | MA | Y |   | Hospitals | Rehabilitation Hospital |   |
No ID Information.