Provider Demographics
NPI:1396227450
Name:BANNING, KATHLEEN ACKLEY (MS)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ACKLEY
Last Name:BANNING
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 WEST ST STE F
Mailing Address - Street 2:
Mailing Address - City:CROMWELL
Mailing Address - State:CT
Mailing Address - Zip Code:06416-4405
Mailing Address - Country:US
Mailing Address - Phone:860-613-9930
Mailing Address - Fax:
Practice Address - Street 1:162 WEST ST STE F
Practice Address - Street 2:
Practice Address - City:CROMWELL
Practice Address - State:CT
Practice Address - Zip Code:06416-4405
Practice Address - Country:US
Practice Address - Phone:860-613-9930
Practice Address - Fax:860-623-9952
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005706225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
347698OtherNBCOT
NH2639OtherSTATE OF NH