Basic Information
| Provider Information | |||||||||
| NPI: | 1417995549 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MICHAEL DALEY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COMMUNITY PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 360 N MAIN ST | ||||||||
| Address2: | SUITE 9 | ||||||||
| City: | SOUTHINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064892503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606217389 | ||||||||
| FaxNumber: | 8606212586 | ||||||||
| Practice Location | |||||||||
| Address1: | 360 N MAIN ST | ||||||||
| Address2: | SUITE 9 | ||||||||
| City: | SOUTHINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064892503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606217389 | ||||||||
| FaxNumber: | 8606212586 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 11/22/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DALEY | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8606217389 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | P.T. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 002030 | CT | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 004252152 | 05 | CT | MEDICAID | 104537400 | 01 | CT | DEPARTMENT OF LABOR | OTHER | 2V83221 | 01 | CT | HEALTHNET | OTHER | 0121901 | 01 | CT | ORTHONET | OTHER | CI7695 | 01 | CT | MEDICARE RAILROAD | OTHER |