Basic Information
| Provider Information | |||||||||
| NPI: | 1962691196 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DONOFRIO | ||||||||
| FirstName: | MARCIA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 175 STAFFORD RD | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD CENTER | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062501441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604568869 | ||||||||
| FaxNumber: | 8604501936 | ||||||||
| Practice Location | |||||||||
| Address1: | 175 STAFFORD RD | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD CENTER | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062501441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604568869 | ||||||||
| FaxNumber: | 8604501936 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2007 | ||||||||
| LastUpdateDate: | 08/15/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 001450 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0116301 | 01 | ORTHONET-HEALTHNET | OTHER | 056002 | 01 | CT | HEALTH NET | OTHER | ANC895 | 01 | CT | OXFORD | OTHER | 080001450CT02 | 01 | CT | BLUE CROSS BLUE SHIELD | OTHER |