Provider Demographics
NPI:1295088151
Name:FORTIN, KATHLEEN SUSAN (PTA)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:SUSAN
Last Name:FORTIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 HEMLOCK CIR
Mailing Address - Street 2:
Mailing Address - City:STAFFORD SPRINGS
Mailing Address - State:CT
Mailing Address - Zip Code:06076-4328
Mailing Address - Country:US
Mailing Address - Phone:860-640-6338
Mailing Address - Fax:
Practice Address - Street 1:1 EMERSON DR
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095-3204
Practice Address - Country:US
Practice Address - Phone:860-640-6338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000997225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant