Provider Demographics
NPI:1841563665
Name:SURIN, NICOLE CASSISTA (DPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:CASSISTA
Last Name:SURIN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 BOSTON POST RD
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-2684
Mailing Address - Country:US
Mailing Address - Phone:203-783-1997
Mailing Address - Fax:203-783-3997
Practice Address - Street 1:400 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CT
Practice Address - Zip Code:06477-3545
Practice Address - Country:US
Practice Address - Phone:203-799-3343
Practice Address - Fax:203-517-0604
Is Sole Proprietor?:No
Enumeration Date:2012-02-10
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT009307225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist