Provider Demographics
NPI:1164653051
Name:ATIMBO, TOM M
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:M
Last Name:ATIMBO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 PALOMBA DR
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-3868
Mailing Address - Country:US
Mailing Address - Phone:860-253-5020
Mailing Address - Fax:860-253-5030
Practice Address - Street 1:2399 BOSTON RD
Practice Address - Street 2:
Practice Address - City:WILBRAHAM
Practice Address - State:MA
Practice Address - Zip Code:01095-1185
Practice Address - Country:US
Practice Address - Phone:413-596-3111
Practice Address - Fax:413-596-9072
Is Sole Proprietor?:No
Enumeration Date:2009-07-27
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT101YM0800X
101YM0800X
MA8468225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health