Individual
MRS. AMY PROVENCAL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PTA
Contact information
Practice address
950 CAMPBELL AVE, WEST HAVEN, CT 06516-2770
(203) 935-5711
Mailing address
139 CHARTER OAK AVE, EAST HAVEN, CT 06512-2704
(203) 467-1974
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
000199
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
22520000X
PHYSICAL THERAPY ASSISTANT
CT
Enumeration date
10/30/2008
Last updated
10/30/2008
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