Provider Demographics
NPI:1023184504
Name:BURSTEIN, MARYELLEN
Entity Type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:
Last Name:BURSTEIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 OLD STONE XING
Mailing Address - Street 2:
Mailing Address - City:WEST SIMSBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06092-2820
Mailing Address - Country:US
Mailing Address - Phone:860-408-1353
Mailing Address - Fax:
Practice Address - Street 1:29 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-1933
Practice Address - Country:US
Practice Address - Phone:860-561-3960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT005360OtherLICENSE#