Provider Demographics
NPI:1023146701
Name:ILLINGWORTH, GEOFFREY RD (PT, ATC)
Entity type:Individual
Prefix:MR
First Name:GEOFFREY
Middle Name:RD
Last Name:ILLINGWORTH
Suffix:
Gender:M
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:VT
Mailing Address - Zip Code:05158-9706
Mailing Address - Country:US
Mailing Address - Phone:802-463-4725
Mailing Address - Fax:
Practice Address - Street 1:36 ADAMS ST
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:VT
Practice Address - Zip Code:05158-9706
Practice Address - Country:US
Practice Address - Phone:802-463-4725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT104-00000152255A2300X
VT040-0002739225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer