Provider Demographics
NPI:1174867113
Name:MYSTIC HEALTHCARE AND REHABILITATION FACILITY
Entity Type:Organization
Organization Name:MYSTIC HEALTHCARE AND REHABILITATION FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED PHYSICAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:DORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:860-536-6070
Mailing Address - Street 1:475 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355-1707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:475 HIGH ST
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-1707
Practice Address - Country:US
Practice Address - Phone:860-536-6070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003480261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy