Provider Demographics
NPI:1275700403
Name:LATHROP, MARY (ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:LATHROP
Suffix:
Gender:F
Credentials:ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 FOGARTY AVE
Mailing Address - Street 2:
Mailing Address - City:GRISWOLD
Mailing Address - State:CT
Mailing Address - Zip Code:06351-1725
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 MOHEGAN AVE
Practice Address - Street 2:MICHEL HALL
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-8100
Practice Address - Country:US
Practice Address - Phone:860-444-8414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0004732255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer