Provider Demographics
NPI:1619486073
Name:GANJANATHAVAT, PATTYA JEAN (LMT)
Entity Type:Individual
Prefix:MS
First Name:PATTYA
Middle Name:JEAN
Last Name:GANJANATHAVAT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303R ISINGLASS RD
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-5708
Mailing Address - Country:US
Mailing Address - Phone:405-613-0731
Mailing Address - Fax:
Practice Address - Street 1:163 BROAD ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-4726
Practice Address - Country:US
Practice Address - Phone:203-513-9594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-28
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT9711225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist