Healthcare Provider Details

I. General information

NPI: 1417047689
Provider Name (Legal Business Name): FALL MOUNTAIN PHYSICAL THERAPY AND ATHLETIC TRAINING, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 11/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 NH ROUTE 12A
LANGDON NH
03602-8221
US

IV. Provider business mailing address

PO BOX 57
ALSTEAD NH
03602-0057
US

V. Phone/Fax

Practice location:
  • Phone: 603-835-7828
  • Fax: 603-835-7827
Mailing address:
  • Phone: 603-835-7828
  • Fax: 603-835-7827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2994
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0036
License Number StateNH

VIII. Authorized Official

Name: MRS. LISA N YOUNG
Title or Position: OWNER, PT, ATC
Credential: MPT, ATC
Phone: 603-835-7828