Provider Demographics
NPI:1578636262
Name:LECONCHE, JODIE (PTA)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:
Last Name:LECONCHE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 PATRICIA GENOVA DRIVE
Mailing Address - Street 2:EASTERN REHABILITATION NETWORK (5TH FLOOR)
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111
Mailing Address - Country:US
Mailing Address - Phone:860-667-5480
Mailing Address - Fax:860-667-8416
Practice Address - Street 1:181 PATRICIA GENOVA DRIVE
Practice Address - Street 2:EASTERN REHABILITATION NETWORK (5TH FLOOR)
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111
Practice Address - Country:US
Practice Address - Phone:860-667-5480
Practice Address - Fax:860-667-8416
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000859225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant