Healthcare Provider Details

I. General information

NPI: 1780936120
Provider Name (Legal Business Name): STAYHOMEPT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2012
Last Update Date: 10/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

827 MAIN ST
SOUTH GLASTONBURY CT
06073-2217
US

IV. Provider business mailing address

827 MAIN ST
SOUTH GLASTONBURY CT
06073-2217
US

V. Phone/Fax

Practice location:
  • Phone: 860-916-7916
  • Fax:
Mailing address:
  • Phone: 860-916-7916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number005057
License Number StateCT

VIII. Authorized Official

Name: DARLENE M MAHONEY
Title or Position: OWNER
Credential: MS, PT
Phone: 860-916-7916