Provider Demographics
NPI:1316674617
Name:DETIENNE, JOHN (PT, DPT, RYT-200)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:DETIENNE
Suffix:
Gender:M
Credentials:PT, DPT, RYT-200
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 WESTOVER RD
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-1929
Mailing Address - Country:US
Mailing Address - Phone:202-213-6047
Mailing Address - Fax:
Practice Address - Street 1:HSS SPORTS REHAB
Practice Address - Street 2:564 SOUTH AVENUE
Practice Address - City:NEW CANAAN
Practice Address - State:CT
Practice Address - Zip Code:06840
Practice Address - Country:US
Practice Address - Phone:203-276-8597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-05
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT012450225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist