Provider Demographics
NPI:1922129451
Name:DEGRUTTOLA, MARY ANN (RPT)
Entity Type:Individual
Prefix:MRS
First Name:MARY ANN
Middle Name:
Last Name:DEGRUTTOLA
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 PEASE LN
Mailing Address - Street 2:P.O. BOX 349
Mailing Address - City:SOUTH GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06073-2015
Mailing Address - Country:US
Mailing Address - Phone:860-659-2243
Mailing Address - Fax:
Practice Address - Street 1:72 SALMON BROOK DR
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2131
Practice Address - Country:US
Practice Address - Phone:860-633-4452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT591225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist