Provider Demographics
NPI:1649493644
Name:CANTON PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:CANTON PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:DEVLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-693-6226
Mailing Address - Street 1:PO BOX 466
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:CT
Mailing Address - Zip Code:06019
Mailing Address - Country:US
Mailing Address - Phone:860-693-6226
Mailing Address - Fax:860-693-8002
Practice Address - Street 1:65 ALBANY TPKE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:CT
Practice Address - Zip Code:06019-2507
Practice Address - Country:US
Practice Address - Phone:860-693-6226
Practice Address - Fax:860-693-8002
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CANTON PHYSICAL THERAPY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-10
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
CT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03076Medicare PIN