Provider Demographics
NPI:1417325374
Name:TRADING SPACES ABA, LLC
Entity Type:Organization
Organization Name:TRADING SPACES ABA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GLENROY
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:PATTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:BCBS
Authorized Official - Phone:321-914-7430
Mailing Address - Street 1:72 BIRCHWOOD RD
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06118-1702
Mailing Address - Country:US
Mailing Address - Phone:321-914-7430
Mailing Address - Fax:860-812-2399
Practice Address - Street 1:72 BIRCHWOOD RD
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06118-1702
Practice Address - Country:US
Practice Address - Phone:321-914-7430
Practice Address - Fax:860-812-2399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11211741103K00000X
CT225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008059673Medicaid