Provider Demographics
NPI:1861634206
Name:FORTIN, LYNN SUSAN (PT)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:SUSAN
Last Name:FORTIN
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 1:111 CEDARWOOD RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:NH
Mailing Address - Zip Code:03603-4118
Mailing Address - Country:US
Mailing Address - Phone:603-542-7193
Mailing Address - Fax:
Practice Address - Street 1:111 CEDARWOOD RD
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:NH
Practice Address - Zip Code:03603-4118
Practice Address - Country:US
Practice Address - Phone:603-542-7193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-31
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHNH1142225100000X
VT0400003311225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist