Provider Demographics
NPI:1659799823
Name:WIRTALLA, BRIAN (DPT, CSCS)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:WIRTALLA
Suffix:
Gender:M
Credentials:DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 PATRICIA M GENOVA DR
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-1500
Mailing Address - Country:US
Mailing Address - Phone:860-696-2550
Mailing Address - Fax:860-696-2525
Practice Address - Street 1:29 HAYNES ST
Practice Address - Street 2:SUITE A
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4139
Practice Address - Country:US
Practice Address - Phone:860-649-2267
Practice Address - Fax:860-654-9753
Is Sole Proprietor?:No
Enumeration Date:2014-04-03
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT9872225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist