Provider Demographics
NPI:1376638742
Name:GALAMGAM, CLINT (MSPT)
Entity Type:Individual
Prefix:
First Name:CLINT
Middle Name:
Last Name:GALAMGAM
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 GLASTONBURY BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033
Mailing Address - Country:US
Mailing Address - Phone:860-633-6292
Mailing Address - Fax:860-633-6299
Practice Address - Street 1:84 GLASTONBURY BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033
Practice Address - Country:US
Practice Address - Phone:860-633-6292
Practice Address - Fax:860-633-6299
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007203225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004252037Medicaid
CT004252037Medicaid