Provider Demographics
NPI:1952791329
Name:CONNECTICUT DANCE PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:CONNECTICUT DANCE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIMATTIA
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:203-569-1274
Mailing Address - Street 1:1275 SUMMER ST
Mailing Address - Street 2:SUITE 307
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-5359
Mailing Address - Country:US
Mailing Address - Phone:203-569-1274
Mailing Address - Fax:
Practice Address - Street 1:1275 SUMMER ST
Practice Address - Street 2:SUITE 307
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5359
Practice Address - Country:US
Practice Address - Phone:203-569-1274
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-23
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0006532261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy