Provider Demographics
NPI:1740229715
Name:MCQUILLAN, KERRI A (PT)
Entity Type:Individual
Prefix:
First Name:KERRI
Middle Name:A
Last Name:MCQUILLAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 KENSINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06051-3916
Mailing Address - Country:US
Mailing Address - Phone:860-224-6231
Mailing Address - Fax:860-224-6260
Practice Address - Street 1:292 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06052-1321
Practice Address - Country:US
Practice Address - Phone:860-224-2631
Practice Address - Fax:860-223-4117
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006045225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT2V9634OtherHEALTH NET
CT7257930OtherAETNA
CT9491004OtherMULTIPLAN
CT080006045CT02OtherBCBS, BCFP, MEDIBLUE
CT401956OtherWELLCARE MEDICARE