Provider Demographics
NPI:1265778641
Name:VERILLO, SAMANTHA GRACE (COTA/L)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:GRACE
Last Name:VERILLO
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 1:50 PIERCE ST
Mailing Address - Street 2:UNIT 36
Mailing Address - City:PLAINVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06062-3300
Mailing Address - Country:US
Mailing Address - Phone:860-794-8033
Mailing Address - Fax:
Practice Address - Street 1:1 EMILY WAY
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-3136
Practice Address - Country:US
Practice Address - Phone:860-561-7022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-12
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001065224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant