Basic Information
| Provider Information | |||||||||
| NPI: | 1265799365 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IVYREHAB CONNECTICUT, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1311 MAMARONECK AVE STE 140 | ||||||||
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| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106055224 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 143 SOUND BEACH AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | OLD GREENWICH | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068701736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8664897342 | ||||||||
| FaxNumber: | 6315805222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2012 | ||||||||
| LastUpdateDate: | 08/12/2022 | ||||||||
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| AuthorizedOfficialLastName: | RUCKER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9142944050 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225X00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.