Basic Information
| Provider Information | |||||||||
| NPI: | 1487734992 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALLETT | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | II | ||||||||
| Credential: | PT,DPT,CERT,MDT,CKTP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 256 S GORDON DR | ||||||||
| Address2: | |||||||||
| City: | OAK HARBOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434491541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195595591 | ||||||||
| FaxNumber: | 8662685006 | ||||||||
| Practice Location | |||||||||
| Address1: | 4210 W SYLVANIA AVE STE 102 | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436234501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195595591 | ||||||||
| FaxNumber: | 8662685006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 10/10/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT 010498 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 2632173 | 05 | OH | MEDICAID |