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General NPI Number Information
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NPI Number | 1821829037
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Entity Type | Individual
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Provider Name | ETHAN TYLER PEARSON DPT
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Gender | Male
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Dates
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Enumeration Date | 08/09/2024
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Last Update Date | 09/25/2024
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Provider Practice Location Address
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Address Line | 1231 FARMINGTON AVE
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City | BERLIN
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State | CT
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Zip | 06037-2301
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Country | US
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Telephone | 860-827-1333
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Fax |
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Provider Business Mailing Address
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Address Line | 125 REDWOOD DR
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City | BRISTOL
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State | CT
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Zip | 06010-2417
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Country | US
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Telephone | 860-385-3550
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 14652
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License Number State | CT
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