Healthcare Provider Details

I. General information

NPI: 1982055216
Provider Name (Legal Business Name): JONATHAN BARLOW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2016
Last Update Date: 06/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 TOMPKINS ST
WATERBURY CT
06708-1458
US

IV. Provider business mailing address

22 TOMPKINS ST
WATERBURY CT
06708-1458
US

V. Phone/Fax

Practice location:
  • Phone: 203-419-0381
  • Fax: 203-419-0389
Mailing address:
  • Phone: 203-419-0381
  • Fax: 203-419-0389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1325
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: