Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0019X | Occupational Therapist - Physical Rehabilitation | 002764 | CT |
NPI | 1043665086 |
---|---|
Provider Name | Scott Fidrych |
First Address | Colchester, CT 06415-2509 |
Second Address | Colchester, CT 06415-2509 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/04/2016 |
Last Update Date | 27/04/2016 |