Provider Demographics
NPI:1598999773
Name:FULL SPECTRUM THERAPEUTICS LLC
Entity Type:Organization
Organization Name:FULL SPECTRUM THERAPEUTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MANGE
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:860-919-1222
Mailing Address - Street 1:4 SUMMIT RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:PROSPECT
Mailing Address - State:CT
Mailing Address - Zip Code:06712-1485
Mailing Address - Country:US
Mailing Address - Phone:203-758-0755
Mailing Address - Fax:203-758-0754
Practice Address - Street 1:4 SUMMIT RD
Practice Address - Street 2:SUITE C
Practice Address - City:PROSPECT
Practice Address - State:CT
Practice Address - Zip Code:06712-1485
Practice Address - Country:US
Practice Address - Phone:203-758-0755
Practice Address - Fax:203-758-0754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-04
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001841261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities