Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | 003751 | CT |
NPI | 1003155953 |
---|---|
Provider Name | Justine Kennan |
First Address | Sandy Hook, CT 06482-1362 |
Second Address | Sandy Hook, CT 06482-1362 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/02/2013 |
Last Update Date | 12/02/2013 |