Provider Demographics
NPI:1063650901
Name:BLACK ROCK PHYSICAL THERAPY
Entity Type:Organization
Organization Name:BLACK ROCK PHYSICAL THERAPY
Other - Org Name:TLCPT
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TARA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:PT, IMTC, CSCS
Authorized Official - Phone:203-345-1720
Mailing Address - Street 1:2889 FAIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06605-3211
Mailing Address - Country:US
Mailing Address - Phone:203-335-1987
Mailing Address - Fax:203-549-0725
Practice Address - Street 1:2889 FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06605-3211
Practice Address - Country:US
Practice Address - Phone:203-335-1987
Practice Address - Fax:203-549-0725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-30
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004078261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD100000150OtherMEDICARE PTAN