Provider Demographics
NPI:1306216395
Name:PIASECKI, EVAN JAMES (LMT)
Entity Type:Individual
Prefix:MR
First Name:EVAN
Middle Name:JAMES
Last Name:PIASECKI
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MARKET SQ
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-2921
Mailing Address - Country:US
Mailing Address - Phone:860-770-0954
Mailing Address - Fax:
Practice Address - Street 1:100 MARKET SQ
Practice Address - Street 2:SUITE 1
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-2921
Practice Address - Country:US
Practice Address - Phone:860-770-0954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-02
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007224225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist