Basic Information
| Provider Information | |||||||||
| NPI: | 1184734691 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REALE | ||||||||
| FirstName: | ANTONIO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8 ROSE ST UNIT 20-4 | ||||||||
| Address2: | |||||||||
| City: | DANBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068105820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8456123244 | ||||||||
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| Practice Location | |||||||||
| Address1: | 131 KENT RD | ||||||||
| Address2: | |||||||||
| City: | NEW MILFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067763485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603503330 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 007400 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 007400 | 01 | CT | LICENSE # | OTHER |