Provider Demographics
NPI:1396108270
Name:MARDAL, IRENE (LMT)
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:MARDAL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 WOOSTER ST
Mailing Address - Street 2:APARTMENT REAR
Mailing Address - City:BETHEL
Mailing Address - State:CT
Mailing Address - Zip Code:06801-1832
Mailing Address - Country:US
Mailing Address - Phone:203-448-9184
Mailing Address - Fax:
Practice Address - Street 1:100 REDDING RD
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CT
Practice Address - Zip Code:06896-3236
Practice Address - Country:US
Practice Address - Phone:203-544-7733
Practice Address - Fax:203-544-1200
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000932225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist