Basic Information
| Provider Information | |||||||||
| NPI: | 1053760157 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLY | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 417594 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022417594 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142944050 | ||||||||
| FaxNumber: | 2077999340 | ||||||||
| Practice Location | |||||||||
| Address1: | 2520 MAIN ST STE 2 | ||||||||
| Address2: | |||||||||
| City: | GLASTONBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060334250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604308383 | ||||||||
| FaxNumber: | 8608566945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2016 | ||||||||
| LastUpdateDate: | 06/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT4733 | ME | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 011339 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.