Provider Demographics
NPI:1821337064
Name:BERGHORN, KEVIN P (DPT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:P
Last Name:BERGHORN
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 1:360 N MAIN ST STE 9
Mailing Address - Street 2:COMMUNITY PHYSICAL THERAPY
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-2503
Mailing Address - Country:US
Mailing Address - Phone:860-621-7389
Mailing Address - Fax:860-621-7389
Practice Address - Street 1:360 N MAIN ST STE 9
Practice Address - Street 2:COMMUNITY PHYSICAL THERAPY
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-2503
Practice Address - Country:US
Practice Address - Phone:860-621-7389
Practice Address - Fax:860-621-7389
Is Sole Proprietor?:No
Enumeration Date:2013-02-07
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT9667225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT009667OtherCT STATE LICENSE