Healthcare Provider Details

I. General information

NPI: 1689016529
Provider Name (Legal Business Name): ACTIVE PHYSICAL THERAPY AND WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2013
Last Update Date: 02/16/2023
Certification Date: 02/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 LODGE LN
WILBRAHAM MA
01095-1629
US

IV. Provider business mailing address

2 LODGE LN
WILBRAHAM MA
01095-1629
US

V. Phone/Fax

Practice location:
  • Phone: 413-596-5363
  • Fax:
Mailing address:
  • Phone: 413-596-5363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: LAWRENCE G. SANTILLI
Title or Position: MANAGER
Credential:
Phone: 860-751-3900