Healthcare Provider Details

I. General information

NPI: 1336404847
Provider Name (Legal Business Name): KURTIS LILLIE PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2012
Last Update Date: 07/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 ENSIGN DR THE PERFECT WORKOUT
AVON CT
06001-3773
US

IV. Provider business mailing address

31 ENSIGN DR THE PERFECT WORKOUT
AVON CT
06001-3773
US

V. Phone/Fax

Practice location:
  • Phone: 860-409-9125
  • Fax:
Mailing address:
  • Phone: 860-409-9125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number14.009466
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: