Healthcare Provider Details

I. General information

NPI: 1841301561
Provider Name (Legal Business Name): MCKIERNAN PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 01/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 TECHNOLOGY DR STE A-200
TRUMBULL CT
06611-6337
US

IV. Provider business mailing address

115 TECHNOLOGY DR STE A-200
TRUMBULL CT
06611-6337
US

V. Phone/Fax

Practice location:
  • Phone: 203-268-5801
  • Fax: 203-452-3688
Mailing address:
  • Phone: 203-268-5801
  • Fax: 203-452-3688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number004917
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number004917
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number004917
License Number StateCT

VIII. Authorized Official

Name: EDWARD G MCKIERNAN
Title or Position: OWNER
Credential: RPT
Phone: 203-268-5801