Provider Demographics
NPI:1376326181
Name:LOCKHART, DAVINA CRYSTAL (LMT)
Entity Type:Individual
Prefix:
First Name:DAVINA
Middle Name:CRYSTAL
Last Name:LOCKHART
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 POMEROY AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-7170
Mailing Address - Country:US
Mailing Address - Phone:203-715-6725
Mailing Address - Fax:
Practice Address - Street 1:240 POMEROY AVE STE 206
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-7170
Practice Address - Country:US
Practice Address - Phone:203-715-6725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11119225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist