Provider Demographics
NPI:1669204590
Name:ROSSAK, RENATA E
Entity type:Individual
Prefix:
First Name:RENATA
Middle Name:E
Last Name:ROSSAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 ISAMAY DR
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-4009
Mailing Address - Country:US
Mailing Address - Phone:860-748-7205
Mailing Address - Fax:
Practice Address - Street 1:2021 ALBANY AVE
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06117-2789
Practice Address - Country:US
Practice Address - Phone:860-570-8266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001451225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant