Provider Demographics
NPI:1235514068
Name:AMITY PHYSICAL THERAPY OF BRANFORD
Entity type:Organization
Organization Name:AMITY PHYSICAL THERAPY OF BRANFORD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DOW
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:203-389-4593
Mailing Address - Street 1:103 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-3034
Mailing Address - Country:US
Mailing Address - Phone:203-433-4683
Mailing Address - Fax:203-208-2048
Practice Address - Street 1:1 BRADLEY RD STE 801
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:CT
Practice Address - Zip Code:06525-2296
Practice Address - Country:US
Practice Address - Phone:203-389-4593
Practice Address - Fax:203-389-4609
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMITY PHYSICAL THERAPY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-22
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00646225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03137Medicare UPIN