Provider Demographics
NPI:1518909100
Name:PHOENIX PHYSICAL THERAPY PLLC
Entity Type:Organization
Organization Name:PHOENIX PHYSICAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JANE
Authorized Official - Middle Name:SUSAN
Authorized Official - Last Name:KAUFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:802-863-6662
Mailing Address - Street 1:1775 WILLISTON RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-6491
Mailing Address - Country:US
Mailing Address - Phone:802-863-6662
Mailing Address - Fax:802-861-2224
Practice Address - Street 1:1775 WILLISTON RD
Practice Address - Street 2:SUITE 104
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-6491
Practice Address - Country:US
Practice Address - Phone:802-863-6662
Practice Address - Fax:802-861-2224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
VT040.0000866332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN2575Medicaid
VT68094OtherBCBS
VT68094OtherBCBS