Basic Information
Provider Information | |||||||||
NPI: | 1326646977 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PATRICK | ||||||||
FirstName: | CHRISTOPHER | ||||||||
MiddleName: | DAVID | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT., DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1377 MOTOR PKWY STE 307 | ||||||||
Address2: |   | ||||||||
City: | ISLANDIA | ||||||||
State: | NY | ||||||||
PostalCode: | 117495258 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6105805200 | ||||||||
FaxNumber: | 6105805222 | ||||||||
Practice Location | |||||||||
Address1: | 385 BRIDGEPORT AVE | ||||||||
Address2: |   | ||||||||
City: | SHELTON | ||||||||
State: | CT | ||||||||
PostalCode: | 064845303 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4758821440 | ||||||||
FaxNumber: | 4752095002 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/15/2020 | ||||||||
LastUpdateDate: | 10/15/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/15/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 12853 | CT | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.