Basic Information
| Provider Information | |||||||||
| NPI: | 1164434981 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DUFFETT | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | GARDNER | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MS,PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 67 BOULDER DR | ||||||||
| Address2: | |||||||||
| City: | LONDONDERRY | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030533789 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034373563 | ||||||||
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| Practice Location | |||||||||
| Address1: | 55 HARRIS RD | ||||||||
| Address2: | |||||||||
| City: | NASHUA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030622145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6038881573 | ||||||||
| FaxNumber: | 6038970514 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2674 | NH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 15760 | MA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT011311L | PA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 2674 | 01 | NH | PHYS THERAPY LICENSE | OTHER | 0334065 | 05 | MA | MEDICAID | PT011311L | 01 | PA | PHYS THERAPY LICENSE | OTHER | 15760 | 01 | MA | PHYS THERAPY LICENSE | OTHER |