Healthcare Provider Details

I. General information

NPI: 1417180266
Provider Name (Legal Business Name): JONATHAN PATRICK PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2009
Last Update Date: 08/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 DAVIS RD W
OLD LYME CT
06371-1448
US

IV. Provider business mailing address

6 DAVIS RD W
OLD LYME CT
06371-1448
US

V. Phone/Fax

Practice location:
  • Phone: 860-434-9155
  • Fax:
Mailing address:
  • Phone: 860-434-9155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2350
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: