Provider Demographics
NPI:1225567670
Name:FERCODINI, COLLEEN
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:FERCODINI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 TOMPKINS ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-1458
Mailing Address - Country:US
Mailing Address - Phone:203-419-0381
Mailing Address - Fax:203-419-0389
Practice Address - Street 1:22 TOMPKINS STREET
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-1458
Practice Address - Country:US
Practice Address - Phone:203-419-0381
Practice Address - Fax:203-419-0389
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT218225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004190328Medicaid