Provider Demographics
NPI:1154506152
Name:LARY, SABRENA DIANA (ATC)
Entity Type:Individual
Prefix:MS
First Name:SABRENA
Middle Name:DIANA
Last Name:LARY
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 BABULA RD
Mailing Address - Street 2:
Mailing Address - City:THOMPSON
Mailing Address - State:CT
Mailing Address - Zip Code:06277-1401
Mailing Address - Country:US
Mailing Address - Phone:860-208-8611
Mailing Address - Fax:
Practice Address - Street 1:330 WESTERN BLVD STE 101
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-4383
Practice Address - Country:US
Practice Address - Phone:860-657-4723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH03342255A2300X
MA16252255A2300X
MO20090032252255A2300X
CT0004382255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer