Provider Demographics
NPI:1255584561
Name:PROVENCAL, AMY (PTA)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:
Last Name:PROVENCAL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 CHARTER OAK AVE
Mailing Address - Street 2:
Mailing Address - City:EAST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06512-2704
Mailing Address - Country:US
Mailing Address - Phone:203-467-1974
Mailing Address - Fax:
Practice Address - Street 1:950 CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-2770
Practice Address - Country:US
Practice Address - Phone:203-935-5711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-30
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000199225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT22520000XOtherPHYSICAL THERAPY ASSISTANT