Provider Demographics
NPI:1902236730
Name:PHYSICAL THERAPY OF SOUTHERN CONNETICUT
Entity Type:Organization
Organization Name:PHYSICAL THERAPY OF SOUTHERN CONNETICUT
Other - Org Name:CHILD & FAMILY NETWORK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAUDE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:203-735-8336
Mailing Address - Street 1:917 BRIDGEPORT AVE
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-4679
Mailing Address - Country:US
Mailing Address - Phone:203-735-8336
Mailing Address - Fax:203-735-3704
Practice Address - Street 1:917 BRIDGEPORT AVE
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-4679
Practice Address - Country:US
Practice Address - Phone:203-735-8336
Practice Address - Fax:203-735-3704
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHYSICAL THERAPY OF SOUTHERN CONNECTICUT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-11-14
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004398203Medicaid