Provider Demographics
NPI:1417176462
Name:WALLINGFORD PHYSICAL THERAPY
Entity Type:Organization
Organization Name:WALLINGFORD PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:VAUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:203-265-2500
Mailing Address - Street 1:350 CENTER ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-4243
Mailing Address - Country:US
Mailing Address - Phone:203-265-2500
Mailing Address - Fax:203-265-9222
Practice Address - Street 1:350 CENTER ST
Practice Address - Street 2:SUITE 104
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-4243
Practice Address - Country:US
Practice Address - Phone:203-265-2500
Practice Address - Fax:203-265-9222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001746225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC02985Medicare ID - Type UnspecifiedGROUP NUMBER