Provider Demographics
NPI:1508299496
Name:ANTOINE, TIRZAH GRACE (PT)
Entity Type:Individual
Prefix:MRS
First Name:TIRZAH
Middle Name:GRACE
Last Name:ANTOINE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TIRZAH
Other - Middle Name:GRACE
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:85 BARNES RD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-1832
Mailing Address - Country:US
Mailing Address - Phone:203-697-1067
Mailing Address - Fax:203-284-0492
Practice Address - Street 1:85 BARNES RD
Practice Address - Street 2:SUITE 109
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-1832
Practice Address - Country:US
Practice Address - Phone:203-697-1067
Practice Address - Fax:203-284-0492
Is Sole Proprietor?:No
Enumeration Date:2013-08-14
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036636225100000X
CT10703225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist