Provider Demographics
NPI:1447419916
Name:FIELDS, JEREMY (PTA, ATC/L)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:FIELDS
Suffix:
Gender:M
Credentials:PTA, ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:481 GOLD STAR HWY
Mailing Address - Street 2:SUITE 302
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-6702
Mailing Address - Country:US
Mailing Address - Phone:860-446-8254
Mailing Address - Fax:860-446-8293
Practice Address - Street 1:47 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-1926
Practice Address - Country:US
Practice Address - Phone:860-409-4595
Practice Address - Fax:860-409-4860
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0004132255A2300X
CT1620225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT120602553OtherNATABOC