| Organization Name: | MYSTIC HEALTHCARE AND REHABILITATION FACILITY |
| NPI Number: | 1174867113 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | SUSAN ELIZABETH DORMAN (REGISTERED PHYSICAL THERAPIST) |
| Mailing Address: | 475 High St Mystic |
| State: | CT US |
| Postal Code: | 063551707 |
| Phone Number: | 8605366070 |
| Fax Number: | |
| NPI Enumeration Date: | 11/15/2012 |
| NPI Last Update Date: | 11/15/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QP2000X |
| License Number: | 003480 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CT |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Physical Therapy |
| Taxonomy Definition: | |