1558430785 NPI number — MRS. JENNY M BRADDOCK PT, OCS

Table of content: MRS. JENNY M BRADDOCK PT, OCS (NPI 1558430785)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558430785 NPI number — MRS. JENNY M BRADDOCK PT, OCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRADDOCK
Provider First Name:
JENNY
Provider Middle Name:
M
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT, OCS
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:
1558430785
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:
247 HILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARWINTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06791-2502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-485-0755
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
117 SHARON RD
Provider Second Line Business Practice Location Address:
MALL VIEW PLAZA
Provider Business Practice Location Address City Name:
WATERBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06705-4000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-756-2334
Provider Business Practice Location Address Fax Number:
203-756-2594
Provider Enumeration Date:
11/06/2006

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:  007053 , 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: 080007053CT01 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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