Provider Demographics
NPI:1578561171
Name:AUGUSTAUSKAS, MARK (RPT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:AUGUSTAUSKAS
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 HOLLEY LANE
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:CT
Mailing Address - Zip Code:06712
Mailing Address - Country:US
Mailing Address - Phone:203-758-6569
Mailing Address - Fax:203-758-0443
Practice Address - Street 1:21 HOLLEY LN
Practice Address - Street 2:93 WATERBURY RD.
Practice Address - City:PROSPECT
Practice Address - State:CT
Practice Address - Zip Code:06712-1484
Practice Address - Country:US
Practice Address - Phone:203-758-6569
Practice Address - Fax:203-758-0443
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002427225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT002427OtherSTATE LICENSE, PHYSICAL T
CT002427OtherSTATE LICENSE, PHYSICAL T