Provider Demographics
NPI:1154420164
Name:HOLTON, THOMAS WAYNE (MSS AT,C)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:WAYNE
Last Name:HOLTON
Suffix:
Gender:M
Credentials:MSS AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 DEER RUN RD
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:CT
Mailing Address - Zip Code:06280-1535
Mailing Address - Country:US
Mailing Address - Phone:860-450-0893
Mailing Address - Fax:
Practice Address - Street 1:83 WINDHAM ST
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2211
Practice Address - Country:US
Practice Address - Phone:860-465-5171
Practice Address - Fax:860-465-4696
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT255A2300X2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer