Provider Demographics
NPI:1063842011
Name:CARDOSO, JARETH
Entity Type:Individual
Prefix:
First Name:JARETH
Middle Name:
Last Name:CARDOSO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2928 MAIN ST STE 2
Mailing Address - Street 2:200
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-1007
Mailing Address - Country:US
Mailing Address - Phone:860-430-2344
Mailing Address - Fax:860-430-2349
Practice Address - Street 1:2928 MAIN ST STE 2
Practice Address - Street 2:200
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-1007
Practice Address - Country:US
Practice Address - Phone:860-430-2344
Practice Address - Fax:860-430-2349
Is Sole Proprietor?:No
Enumeration Date:2013-11-12
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT9977225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist