Healthcare Provider Details

I. General information

NPI: 1851797229
Provider Name (Legal Business Name): ERIC DYSON JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2014
Last Update Date: 11/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145 POQUONNOCK RD
GROTON CT
06340-4620
US

IV. Provider business mailing address

26 DEVONSHIRE DR
WATERFORD CT
06385-1702
US

V. Phone/Fax

Practice location:
  • Phone: 860-446-9960
  • Fax:
Mailing address:
  • Phone: 860-857-4572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number001495
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: