Healthcare Provider Details

I. General information

NPI: 1346744216
Provider Name (Legal Business Name): ATHLETIC EVOLUTION PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2018
Last Update Date: 03/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78C OLYMPIA AVE
WOBURN MA
01801-2057
US

IV. Provider business mailing address

78C OLYMPIA AVE
WOBURN MA
01801-2057
US

V. Phone/Fax

Practice location:
  • Phone: 781-935-7701
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: STEFANIE ROUSSELLE
Title or Position: DIRECTOR
Credential:
Phone: 781-935-7701