Provider Demographics
NPI:1497301154
Name:GANGLOFF, KRISTA (MOTR/L)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:GANGLOFF
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 HARMAN CT
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-3937
Mailing Address - Country:US
Mailing Address - Phone:860-716-7790
Mailing Address - Fax:
Practice Address - Street 1:16 HARMAN CT
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-3937
Practice Address - Country:US
Practice Address - Phone:860-716-7790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004523225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist