Provider Demographics
NPI:1760212047
Name:FAMIGLIETTI, TEGAN
Entity type:Individual
Prefix:
First Name:TEGAN
Middle Name:
Last Name:FAMIGLIETTI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512B KETTLETOWN RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-2645
Mailing Address - Country:US
Mailing Address - Phone:203-232-1425
Mailing Address - Fax:
Practice Address - Street 1:10 PROGRESS DR STE 2B
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-6294
Practice Address - Country:US
Practice Address - Phone:203-239-5512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6041235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist