Provider Demographics
NPI:1760499479
Name:MEZZOMO, JUDITH MARIE (PT)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:MARIE
Last Name:MEZZOMO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:MARIE
Other - Last Name:MEZZOMOPERAULT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:14 SHERRY DRIVE
Mailing Address - Street 2:
Mailing Address - City:EAST HAMPTON
Mailing Address - State:CT
Mailing Address - Zip Code:06424-1016
Mailing Address - Country:US
Mailing Address - Phone:860-267-9125
Mailing Address - Fax:
Practice Address - Street 1:14 SHERRY DRIVE
Practice Address - Street 2:
Practice Address - City:EAST HAMPTON
Practice Address - State:CT
Practice Address - Zip Code:06424-1016
Practice Address - Country:US
Practice Address - Phone:860-267-9125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002663225100000X
0000105242255A2300X
CT0002732255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT080002663CT02OtherBLUE CROSS BLUE SHIELD