Provider Demographics
NPI:1922359165
Name:CARTY, RENEIL JAY (PTA)
Entity Type:Individual
Prefix:
First Name:RENEIL
Middle Name:JAY
Last Name:CARTY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-1078
Mailing Address - Country:US
Mailing Address - Phone:203-365-6443
Mailing Address - Fax:
Practice Address - Street 1:175 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-1078
Practice Address - Country:US
Practice Address - Phone:203-365-6443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-27
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000091225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant