Basic Information
| Provider Information | |||||||||
| NPI: | 1346857851 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MENZE | ||||||||
| FirstName: | EVAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16 MAYBROOK RD STE N | ||||||||
| Address2: | |||||||||
| City: | CAMPBELL HALL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109162741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8456364344 | ||||||||
| FaxNumber: | 8456364355 | ||||||||
| Practice Location | |||||||||
| Address1: | 64 MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | KENT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067571721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609274559 | ||||||||
| FaxNumber: | 2038389181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2020 | ||||||||
| LastUpdateDate: | 09/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 12798 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.