Provider Demographics
NPI:1891833794
Name:RUVOLO, TRACEY (PT)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:RUVOLO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:
Other - Last Name:PARKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:7 ELM ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-3669
Mailing Address - Country:US
Mailing Address - Phone:860-741-2242
Mailing Address - Fax:860-741-2248
Practice Address - Street 1:7 ELM ST
Practice Address - Street 2:SUITE 204
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-3669
Practice Address - Country:US
Practice Address - Phone:860-741-2242
Practice Address - Fax:860-741-2248
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003249225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT076572Medicare ID - Type UnspecifiedGROUP ID