Healthcare Provider Details

I. General information

NPI: 1003591439
Provider Name (Legal Business Name): BACKROADS PHYSICAL THERAPY & WELLNESS PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2023
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

546 THOMAS LN
STOWE VT
05672-5438
US

IV. Provider business mailing address

PO BOX 1342
STOWE VT
05672-1342
US

V. Phone/Fax

Practice location:
  • Phone: 802-585-3155
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE ROUSSEAU
Title or Position: OWNER
Credential:
Phone: 802-585-3155