Basic Information
| Provider Information | |||||||||
| NPI: | 1528511730 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MABRY | ||||||||
| FirstName: | JOSEPH | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 47 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WEST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061071926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604094595 | ||||||||
| FaxNumber: | 8604094860 | ||||||||
| Practice Location | |||||||||
| Address1: | 1211 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067083106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037536043 | ||||||||
| FaxNumber: | 2035743127 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2016 | ||||||||
| LastUpdateDate: | 07/25/2016 | ||||||||
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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 | 225200000X | 1697 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.