Healthcare Provider Details

I. General information

NPI: 1285696997
Provider Name (Legal Business Name): MR. TODD A SOULIERE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: TODD A SOULIERE ATC, CSCS

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 PEARL ST FITCHBURG STATE COLLEGE
FITCHBURG MA
01420-2631
US

IV. Provider business mailing address

380 SQUANTUM RD
JAFFREY NH
03452-6646
US

V. Phone/Fax

Practice location:
  • Phone: 978-665-3774
  • Fax: 978-665-3803
Mailing address:
  • Phone: 603-532-6301
  • Fax: 978-665-3803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1140
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: