1013976703 NPI number — KELLY A MASSUCCI M.ED. OTR/L

Table of content: KELLY A MASSUCCI M.ED. OTR/L (NPI 1013976703)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013976703 NPI number — KELLY A MASSUCCI M.ED. OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MASSUCCI
Provider First Name:
KELLY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.ED. OTR/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013976703
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 FOXCROFT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST HARTFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06119-1018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-523-8677
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
270 FARMINGTON AVE
Provider Second Line Business Practice Location Address:
SUITE 126
Provider Business Practice Location Address City Name:
FARMINGTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06032-1909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-674-1824
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  002268 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00424493500 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3623042 . This is a "AETNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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