Provider Demographics
NPI:1457998510
Name:BANDTLOW, STEVEN (MS, ATC)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:BANDTLOW
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 GLASTONBURY TPKE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:CT
Mailing Address - Zip Code:06480-1029
Mailing Address - Country:US
Mailing Address - Phone:860-550-2924
Mailing Address - Fax:
Practice Address - Street 1:270 MOHEGAN AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4125
Practice Address - Country:US
Practice Address - Phone:806-439-2086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-06
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0008132255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer