Provider Demographics
NPI:1093488462
Name:MELLA, REBECCA ANN (MAATC,LAT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANN
Last Name:MELLA
Suffix:
Gender:F
Credentials:MAATC,LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 GLEN HOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:WEST SIMSBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06092-2609
Mailing Address - Country:US
Mailing Address - Phone:860-944-3003
Mailing Address - Fax:
Practice Address - Street 1:275 MOUNT CARMEL AVE
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-1908
Practice Address - Country:US
Practice Address - Phone:203-582-3723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0000852255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer