Basic Information
| Provider Information | |||||||||
| NPI: | 1265163315 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOGRETTE | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | EDMUND | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2408 WHITNEY AVE | ||||||||
| Address2: | |||||||||
| City: | HAMDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065183209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036260160 | ||||||||
| FaxNumber: | 2032946734 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 N COLONY RD | ||||||||
| Address2: | |||||||||
| City: | WALLINGFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064922407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032940449 | ||||||||
| FaxNumber: | 2034668527 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2022 | ||||||||
| LastUpdateDate: | 06/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | CT | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 390200000X | CT | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.