=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235514068
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMITY PHYSICAL THERAPY OF BRANFORD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2015
-----------------------------------------------------
Last Update Date | 07/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 BRADLEY RD STE 801
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06525-2296
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-389-4593
-----------------------------------------------------
Fax | 203-389-4609
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 N MAIN ST
-----------------------------------------------------
City | BRANFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06405-3034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-433-4683
-----------------------------------------------------
Fax | 203-208-2048
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/OWNER
-----------------------------------------------------
Name | MICHAEL DOW
-----------------------------------------------------
Credential | MSPT
-----------------------------------------------------
Telephone | 203-389-4593
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 00646
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------