Provider Demographics
NPI:1881982361
Name:FORTIN, MICHAEL J (PT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:FORTIN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 CRESCENT RD
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-4542
Mailing Address - Country:US
Mailing Address - Phone:203-227-5431
Mailing Address - Fax:877-838-9260
Practice Address - Street 1:22 CRESCENT RD
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-4542
Practice Address - Country:US
Practice Address - Phone:203-227-5431
Practice Address - Fax:877-838-9260
Is Sole Proprietor?:No
Enumeration Date:2011-07-18
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT9134225100000X
SC6842225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist