Basic Information
| Provider Information | |||||||||
| NPI: | 1558840827 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRICKMORE | ||||||||
| FirstName: | ZACHARY | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 435 HARTFORD TPKE STE U | ||||||||
| Address2: | |||||||||
| City: | VERNON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060664834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609791611 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9B FIELDSTONE CMNS | ||||||||
| Address2: | |||||||||
| City: | TOLLAND | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060843421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8608709800 | ||||||||
| FaxNumber: | 8608709806 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2018 | ||||||||
| LastUpdateDate: | 08/08/2018 | ||||||||
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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 | 011948 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 011948 | 01 | CT | LICENSE | OTHER |