Healthcare Provider Details

I. General information

NPI: 1902014178
Provider Name (Legal Business Name): KEITH ALEXANDER LYONS MS, RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2007
Last Update Date: 11/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 MANSFIELD RD
ASHFORD CT
06278-1416
US

IV. Provider business mailing address

430 MANSFIELD RD
ASHFORD CT
06278-1416
US

V. Phone/Fax

Practice location:
  • Phone: 860-573-4923
  • Fax:
Mailing address:
  • Phone: 860-573-4923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number007168
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: