Healthcare Provider Details

I. General information

NPI: 1457674038
Provider Name (Legal Business Name): KIDS REHABGYM INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2010
Last Update Date: 03/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 ROOSEVELT HIGHWAY SUITE 115
COLCHESTER VT
05446-4475
US

IV. Provider business mailing address

905 ROOSEVELT HIGHWAY SUITE 115
COLCHESTER VT
05446-4475
US

V. Phone/Fax

Practice location:
  • Phone: 802-861-3600
  • Fax: 802-861-2812
Mailing address:
  • Phone: 802-861-3600
  • Fax: 802-861-2812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number040-0002123
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number040-0001080
License Number StateVT
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number072-0051238
License Number StateVT
# 4
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number040-0002985
License Number StateVT

VIII. Authorized Official

Name: SHARON GUTWIN
Title or Position: BOARD OF DIRECTORS-PRESIDENT
Credential: PHYSICAL THERAPIST
Phone: 802-876-6000