Provider Demographics
NPI:1154155653
Name:LA PORTE, GRACE (DPT)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:LA PORTE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:274 MASON RD
Mailing Address - Street 2:
Mailing Address - City:MOHAWK
Mailing Address - State:NY
Mailing Address - Zip Code:13407-3902
Mailing Address - Country:US
Mailing Address - Phone:315-717-8264
Mailing Address - Fax:
Practice Address - Street 1:2440 GOLD STAR HWY UNIT 201
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-1180
Practice Address - Country:US
Practice Address - Phone:860-536-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-27
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052932225100000X
CT14591225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist