Provider Demographics
NPI:1134143936
Name:WILBERT, KEITH (PT)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:
Last Name:WILBERT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06052-1318
Mailing Address - Country:US
Mailing Address - Phone:860-225-0674
Mailing Address - Fax:860-223-3330
Practice Address - Street 1:195 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06052-1318
Practice Address - Country:US
Practice Address - Phone:860-225-0674
Practice Address - Fax:860-223-3330
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002360225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT080002360CT02OtherBLUE CROSS
CT650000149Medicare ID - Type Unspecified