Provider Demographics
NPI:1316015928
Name:TYNAN, ELIZABETH L (PT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:L
Last Name:TYNAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:L
Other - Last Name:UPTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:303 LINWOOD AVE
Mailing Address - Street 2:UNIT 1C
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-4900
Mailing Address - Country:US
Mailing Address - Phone:203-218-6988
Mailing Address - Fax:203-459-4249
Practice Address - Street 1:303 LINWOOD AVE
Practice Address - Street 2:UNIT 1C
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-4900
Practice Address - Country:US
Practice Address - Phone:203-218-6988
Practice Address - Fax:203-459-4249
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007056225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03714OtherGROUP PTAN
CT1750585386OtherGROUP NPI
CT650001421OtherMEDICARE PTAN