Provider Demographics
NPI:1134311962
Name:PROVOST, TODD (PTA)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:PROVOST
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 WOODLAND ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-2327
Mailing Address - Country:US
Mailing Address - Phone:860-522-2717
Mailing Address - Fax:860-249-6164
Practice Address - Street 1:673 COTTAGE GROVE RD
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-3033
Practice Address - Country:US
Practice Address - Phone:860-286-1043
Practice Address - Fax:860-286-2836
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA007915225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant