Provider Demographics
NPI:1770951956
Name:MATHIS, ILICIA (DPT)
Entity type:Individual
Prefix:
First Name:ILICIA
Middle Name:
Last Name:MATHIS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BRADLEY RD STE 801
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CT
Mailing Address - Zip Code:06525-2296
Mailing Address - Country:US
Mailing Address - Phone:203-389-4593
Mailing Address - Fax:203-389-4609
Practice Address - Street 1:2285 WHITNEY AVE
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3514
Practice Address - Country:US
Practice Address - Phone:203-691-6248
Practice Address - Fax:203-691-9239
Is Sole Proprietor?:No
Enumeration Date:2015-09-04
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT010594225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist