Provider Demographics
NPI:1245766336
Name:LOVELY, LAUREL
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:
Last Name:LOVELY
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 1:7 RIVERSIDE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:CT
Mailing Address - Zip Code:06480-1952
Mailing Address - Country:US
Mailing Address - Phone:860-834-3341
Mailing Address - Fax:
Practice Address - Street 1:98 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-2803
Practice Address - Country:US
Practice Address - Phone:860-462-6474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-10
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT009246225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist