Healthcare Provider Details

I. General information

NPI: 1316224439
Provider Name (Legal Business Name): MATTHEW PERRELLO L.M.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2011
Last Update Date: 09/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 MAPLE STREET SUITE 203
MIDDLEBURY VT
05753
US

IV. Provider business mailing address

152 MAPLE STREET SUITE 203
MIDDLEBURY VT
05753
US

V. Phone/Fax

Practice location:
  • Phone: 802-349-7565
  • Fax:
Mailing address:
  • Phone: 802-349-7565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60247265
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License NumberMA60247265
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: