Provider Demographics
NPI:1255723557
Name:WIJNDAL, RICARDO (PT)
Entity type:Individual
Prefix:
First Name:RICARDO
Middle Name:
Last Name:WIJNDAL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 CHARTER OAK PL
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-1961
Mailing Address - Country:US
Mailing Address - Phone:860-748-7586
Mailing Address - Fax:
Practice Address - Street 1:14 CHARTER OAK PL
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-1961
Practice Address - Country:US
Practice Address - Phone:860-748-7586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-23
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005645225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT005645OtherLICENSE