Provider Demographics
NPI:1952702680
Name:CENTER FOR PEDIATRIC THERAPY
Entity Type:Organization
Organization Name:CENTER FOR PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH AND LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSCILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-949-9337
Mailing Address - Street 1:101 N PLAINS INDUSTRIAL RD
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2360
Mailing Address - Country:US
Mailing Address - Phone:203-949-9337
Mailing Address - Fax:203-284-3779
Practice Address - Street 1:1300 POST RD STE 204
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-6038
Practice Address - Country:US
Practice Address - Phone:203-255-3669
Practice Address - Fax:203-254-3790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-12
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004880235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty