Provider Demographics
NPI:1497926927
Name:SCOVILLE, HOLLY (PT)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:SCOVILLE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 JOLLEY DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-3092
Mailing Address - Country:US
Mailing Address - Phone:860-286-8882
Mailing Address - Fax:860-286-5481
Practice Address - Street 1:15 MASSIRIO DR
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:CT
Practice Address - Zip Code:06037-2300
Practice Address - Country:US
Practice Address - Phone:860-829-1300
Practice Address - Fax:860-829-1388
Is Sole Proprietor?:No
Enumeration Date:2008-03-12
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006418225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT076573Medicare Oscar/Certification