Provider Demographics
NPI:1780936120
Name:STAYHOMEPT
Entity type:Organization
Organization Name:STAYHOMEPT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DARLENE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MAHONEY
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PT
Authorized Official - Phone:860-916-7916
Mailing Address - Street 1:827 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06073-2217
Mailing Address - Country:US
Mailing Address - Phone:860-916-7916
Mailing Address - Fax:
Practice Address - Street 1:827 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTH GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06073-2217
Practice Address - Country:US
Practice Address - Phone:860-916-7916
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-09
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005057225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty