Provider Demographics
NPI:1306386818
Name:VAZANA, NISSIM (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:NISSIM
Middle Name:
Last Name:VAZANA
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 GIRARD AVE
Mailing Address - Street 2:APT 302
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-2282
Mailing Address - Country:US
Mailing Address - Phone:860-770-4075
Mailing Address - Fax:
Practice Address - Street 1:2701 SOUTHAMPTON RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19154-1205
Practice Address - Country:US
Practice Address - Phone:215-856-2700
Practice Address - Fax:215-856-2777
Is Sole Proprietor?:No
Enumeration Date:2017-03-02
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4740225X00000X
PAOC014956225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist