Provider Demographics
NPI:1285780379
Name:BRACKETT, DIANE (PHD)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:
Last Name:BRACKETT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 POND HILL RD
Mailing Address - Street 2:
Mailing Address - City:MOOSUP
Mailing Address - State:CT
Mailing Address - Zip Code:06354-1836
Mailing Address - Country:US
Mailing Address - Phone:860-564-1508
Mailing Address - Fax:
Practice Address - Street 1:354 HARTFORD TPKE
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:CT
Practice Address - Zip Code:06247-1320
Practice Address - Country:US
Practice Address - Phone:860-455-1404
Practice Address - Fax:860-455-1396
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000359235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist