Provider Demographics
NPI:1578042784
Name:FALLIS, DYLAN (DPT)
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:
Last Name:FALLIS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 42
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06011-0042
Mailing Address - Country:US
Mailing Address - Phone:860-973-4995
Mailing Address - Fax:860-973-4996
Practice Address - Street 1:190 FENN RD
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-2244
Practice Address - Country:US
Practice Address - Phone:860-665-1177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT14.011964225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist