Provider Demographics
NPI:1922582253
Name:DIZENZO, SANDRA LEE (COTA/L)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LEE
Last Name:DIZENZO
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 S COVE RD
Mailing Address - Street 2:
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-2585
Mailing Address - Country:US
Mailing Address - Phone:860-391-8444
Mailing Address - Fax:
Practice Address - Street 1:88 NOTCH HILL RD
Practice Address - Street 2:
Practice Address - City:NORTH BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06471-1846
Practice Address - Country:US
Practice Address - Phone:203-488-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-22
Last Update Date:2018-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001041224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant