Provider Demographics
NPI:1871678045
Name:PERREAULT, ROLAND J (PT)
Entity type:Individual
Prefix:
First Name:ROLAND
Middle Name:J
Last Name:PERREAULT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 DEPOT ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06795-2601
Mailing Address - Country:US
Mailing Address - Phone:860-274-4092
Mailing Address - Fax:860-274-4099
Practice Address - Street 1:27 DEPOT ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:CT
Practice Address - Zip Code:06795-2601
Practice Address - Country:US
Practice Address - Phone:860-274-1487
Practice Address - Fax:860-274-9730
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2008-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3018225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT080003018CT06OtherANTHEM BC BS
CT080003018CT07OtherANTHEM BC BS