Provider Demographics
NPI:1972557528
Name:SCALLON, KRISTEN M (PT)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:M
Last Name:SCALLON
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 1:226 WHITE ST
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-6814
Mailing Address - Country:US
Mailing Address - Phone:203-743-8817
Mailing Address - Fax:
Practice Address - Street 1:31 OLD ROUTE 7
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:CT
Practice Address - Zip Code:06804-1711
Practice Address - Country:US
Practice Address - Phone:203-740-0020
Practice Address - Fax:203-740-7354
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006365225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT650000531OtherMEDIDCARE PTAN
CT004210118Medicaid