Provider Demographics
NPI:1861682296
Name:DYNAMIC PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:DYNAMIC PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:E
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:860-599-0819
Mailing Address - Street 1:158 SOUTH BROAD STREET
Mailing Address - Street 2:
Mailing Address - City:PAWCATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06379-1925
Mailing Address - Country:US
Mailing Address - Phone:860-599-0819
Mailing Address - Fax:860-599-0871
Practice Address - Street 1:158 SOUTH BROAD STREET
Practice Address - Street 2:
Practice Address - City:PAWCATUCK
Practice Address - State:CT
Practice Address - Zip Code:06379-1925
Practice Address - Country:US
Practice Address - Phone:860-599-0819
Practice Address - Fax:860-599-0871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-01
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004925261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT07-6570Medicare PIN