Provider Demographics
NPI:1326109737
Name:VANDOMBURG SCIPIO, ALISA JOAN (OTR)
Entity Type:Individual
Prefix:MS
First Name:ALISA
Middle Name:JOAN
Last Name:VANDOMBURG SCIPIO
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:ALISA
Other - Middle Name:JOAN
Other - Last Name:MEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:192 ALDEN AVE
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06515-2112
Mailing Address - Country:US
Mailing Address - Phone:203-507-2166
Mailing Address - Fax:
Practice Address - Street 1:1931 BLACK ROCK TPKE
Practice Address - Street 2:REHABILITATION ASSOCIATES, INC
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-3506
Practice Address - Country:US
Practice Address - Phone:203-384-8681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2009-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003409225X00000X
NY014962225X00000X
VT072-0000512225XP0200X
NH1828225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics