Provider Demographics
NPI:1992141402
Name:CIASULLI, JENNIFER T (OT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:T
Last Name:CIASULLI
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ERIN
Other - Last Name:TARBELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:5 LAKE RD
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-2967
Mailing Address - Country:US
Mailing Address - Phone:203-922-3674
Mailing Address - Fax:
Practice Address - Street 1:5 LAKE RD
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-2967
Practice Address - Country:US
Practice Address - Phone:203-922-3674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-13
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002573225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist