Provider Demographics
NPI:1144206939
Name:SIRES, CAROLYN A (RPT)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:A
Last Name:SIRES
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-4401
Mailing Address - Country:US
Mailing Address - Phone:203-937-6150
Mailing Address - Fax:203-937-8517
Practice Address - Street 1:544 CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-4401
Practice Address - Country:US
Practice Address - Phone:203-937-6150
Practice Address - Fax:203-937-8517
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003257225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT080003257CT4OtherANTHEM BCBS