Provider Demographics
NPI:1194993485
Name:LACARIA, LORI JEAN (PT MS CLT)
Entity type:Individual
Prefix:MRS
First Name:LORI JEAN
Middle Name:
Last Name:LACARIA
Suffix:
Gender:F
Credentials:PT MS CLT
Other - Prefix:
Other - First Name:LORI JEAN
Other - Middle Name:
Other - Last Name:MARCELLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:270 FARMINGTON AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-1909
Mailing Address - Country:US
Mailing Address - Phone:860-409-4595
Mailing Address - Fax:
Practice Address - Street 1:27 DEPOT ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:CT
Practice Address - Zip Code:06795-2601
Practice Address - Country:US
Practice Address - Phone:860-274-1487
Practice Address - Fax:860-274-4860
Is Sole Proprietor?:No
Enumeration Date:2008-02-20
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002876225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT650000687OtherMEDICARE
CT080002876CT03OtherANTHEM BC BS