Provider Demographics
NPI:1164585451
Name:PHYSICAL THERAPY OF SOUTHERN CONNECTICUT, P.C.
Entity Type:Organization
Organization Name:PHYSICAL THERAPY OF SOUTHERN CONNECTICUT, P.C.
Other - Org Name:
Other - Org Type:
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:RPT
Authorized Official - Phone:203-735-8336
Mailing Address - Street 1:111 NEW HAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-2197
Mailing Address - Country:US
Mailing Address - Phone:203-735-8336
Mailing Address - Fax:203-735-3704
Practice Address - Street 1:111 NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:CT
Practice Address - Zip Code:06418-2197
Practice Address - Country:US
Practice Address - Phone:203-735-8336
Practice Address - Fax:203-735-3704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004398203Medicaid
CT50PTSOUTHPT01OtherANTHEM BLUE CROSS
CTOV1301OtherHEALTHNET
CTANC1153OtherOXFORD HEALTH PLANS
CTOV1301OtherHEALTHNET