Provider Demographics
NPI:1417047689
Name:FALL MOUNTAIN PHYSICAL THERAPY AND ATHLETIC TRAINING, PLLC
Entity Type:Organization
Organization Name:FALL MOUNTAIN PHYSICAL THERAPY AND ATHLETIC TRAINING, PLLC
Other - Org Name:FMPTAT
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER, PT, ATC
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:N
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MPT, ATC
Authorized Official - Phone:603-835-7828
Mailing Address - Street 1:PO BOX 57
Mailing Address - Street 2:
Mailing Address - City:ALSTEAD
Mailing Address - State:NH
Mailing Address - Zip Code:03602-0057
Mailing Address - Country:US
Mailing Address - Phone:603-835-7828
Mailing Address - Fax:603-835-7827
Practice Address - Street 1:122 NH ROUTE 12A
Practice Address - Street 2:
Practice Address - City:LANGDON
Practice Address - State:NH
Practice Address - Zip Code:03602-8221
Practice Address - Country:US
Practice Address - Phone:603-835-7828
Practice Address - Fax:603-835-7827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2994225100000X
NH00362255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHAA65774OtherHARVARD PILGRIM
NH6007380OtherMVP
NH08Y007675NH03OtherANTHEM BCBS
NH30394477Medicaid
NHDF1145OtherRAILROAD MEDICARE
NHAA65774OtherHARVARD PILGRIM