Provider Demographics
NPI:1336483916
Name:STILLWAY, CHANELLE (PT)
Entity Type:Individual
Prefix:
First Name:CHANELLE
Middle Name:
Last Name:STILLWAY
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 1:6448 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-2075
Mailing Address - Country:US
Mailing Address - Phone:203-220-8796
Mailing Address - Fax:
Practice Address - Street 1:6448 MAIN ST
Practice Address - Street 2:
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-2075
Practice Address - Country:US
Practice Address - Phone:203-220-8796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007952225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist