Provider Demographics
NPI:1528275872
Name:COMMUNITY PHYSICAL THERAPY
Entity type:Organization
Organization Name:COMMUNITY PHYSICAL THERAPY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:DALEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:860-621-7389
Mailing Address - Street 1:360 N MAIN ST STE 9
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-2503
Mailing Address - Country:US
Mailing Address - Phone:860-621-7389
Mailing Address - Fax:
Practice Address - Street 1:421 WOLCOTT RD
Practice Address - Street 2:UNIT C
Practice Address - City:WOLCOTT
Practice Address - State:CT
Practice Address - Zip Code:06716-2661
Practice Address - Country:US
Practice Address - Phone:203-879-0107
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002030225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC02482Medicare ID - Type Unspecified