Provider Demographics
NPI:1578572574
Name:TRAYLOR, AUDREY JO (PT)
Entity Type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:JO
Last Name:TRAYLOR
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 1:2B LEE RD
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:CT
Mailing Address - Zip Code:06351-3042
Mailing Address - Country:US
Mailing Address - Phone:860-376-2564
Mailing Address - Fax:860-376-4812
Practice Address - Street 1:2B LEE ROAD
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:CT
Practice Address - Zip Code:06351
Practice Address - Country:US
Practice Address - Phone:860-376-2564
Practice Address - Fax:860-376-4812
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007223225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT080007223CT04OtherBCBS
CT004235801Medicaid
CT650000871Medicare ID - Type Unspecified