Provider Demographics
NPI:1457825515
Name:LITTLE ANTZ LLC
Entity Type:Organization
Organization Name:LITTLE ANTZ LLC
Other - Org Name:INFANT MASSAGE LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LETICIA
Authorized Official - Middle Name:S
Authorized Official - Last Name:JACQUET
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:860-251-9754
Mailing Address - Street 1:1022 BOULEVARD # 274
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-1801
Mailing Address - Country:US
Mailing Address - Phone:860-251-9754
Mailing Address - Fax:
Practice Address - Street 1:776 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119-1677
Practice Address - Country:US
Practice Address - Phone:860-251-9754
Practice Address - Fax:860-969-0821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-11
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1043542657Medicaid