Healthcare Provider Details

I. General information

NPI: 1225358310
Provider Name (Legal Business Name): PROVENCHER PHYSICAL THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2010
Last Update Date: 06/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 S MAIN ST
WATERBURY VT
05676-1579
US

IV. Provider business mailing address

137 S MAIN ST
WATERBURY VT
05676-1579
US

V. Phone/Fax

Practice location:
  • Phone: 802-244-1140
  • Fax:
Mailing address:
  • Phone: 802-244-1140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number040-0002724
License Number StateVT

VIII. Authorized Official

Name: MRS. KATHLEEN C. PROVENCHER
Title or Position: OWNER
Credential:
Phone: 802-324-5138