Provider Demographics
NPI:1669038519
Name:GAYDOS, CARRIE (ATC, L)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:GAYDOS
Suffix:
Gender:F
Credentials:ATC, L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 MEADOWVIEW CT
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-4643
Mailing Address - Country:US
Mailing Address - Phone:860-666-8019
Mailing Address - Fax:
Practice Address - Street 1:58 MEADOWVIEW CT
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-4643
Practice Address - Country:US
Practice Address - Phone:860-666-8019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-16
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT059402395OtherATHLETIC TRAINER