Healthcare Provider Details

I. General information

NPI: 1861977118
Provider Name (Legal Business Name): JAMES LAISO PT, DPT, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2018
Last Update Date: 10/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 MAIN ST STE 1D
STRATFORD CT
06614-4946
US

IV. Provider business mailing address

1931 BLACK ROCK TPKE
FAIRFIELD CT
06825-3506
US

V. Phone/Fax

Practice location:
  • Phone: 203-378-0092
  • Fax: 203-375-4540
Mailing address:
  • Phone: 203-384-8681
  • Fax: 203-384-0722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11915
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: