Provider Demographics
NPI:1932516119
Name:INTEGRATED PHYSICAL THERAPY AND PAIN MANAGEMENT, LLC
Entity Type:Organization
Organization Name:INTEGRATED PHYSICAL THERAPY AND PAIN MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:DJOANA CLARA
Authorized Official - Middle Name:HERRERA
Authorized Official - Last Name:BAKANI
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:203-252-6989
Mailing Address - Street 1:20 BYRAM SHORE RD
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-6926
Mailing Address - Country:US
Mailing Address - Phone:203-252-6989
Mailing Address - Fax:
Practice Address - Street 1:67 HOLLY HILL LN STE 101
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-6072
Practice Address - Country:US
Practice Address - Phone:203-252-6989
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-19
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007561261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400194066OtherPTAN