Provider Demographics
NPI:1669172615
Name:WASZCZAK, PATRICK LIBOR
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:LIBOR
Last Name:WASZCZAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 HUBBARD ST
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-2933
Mailing Address - Country:US
Mailing Address - Phone:860-884-0924
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:800-385-2527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-08
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT484022225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist