Basic Information
| Provider Information | |||||||||
| NPI: | 1134281587 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOUGLASS | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | PT, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22 TOMPKINS ST | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067081458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2034190381 | ||||||||
| FaxNumber: | 2034190389 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 TOMPKINS ST | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067081458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2034190381 | ||||||||
| FaxNumber: | 2034190389 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 03/08/2013 | ||||||||
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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 | 006694 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2255A2300X | 000174 | CT | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
ID Information
| ID | Type | State | Issuer | Description | 006694 | 01 | CT | PHYSICAL THERAPY LICENSE | OTHER | 004190328 | 05 | CT | MEDICAID | 000174 | 01 | CT | ATC LICENSE | OTHER |