Provider Demographics
NPI:1003824707
Name:BOULLI, RICHARD B JR (PT)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:B
Last Name:BOULLI
Suffix:JR
Gender:M
Credentials:PT
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Mailing Address - Street 1:245 ALVORD PARK ROAD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790-3493
Mailing Address - Country:US
Mailing Address - Phone:960-496-9851
Mailing Address - Fax:860-482-4047
Practice Address - Street 1:245 ALVORD PARK ROAD
Practice Address - Street 2:SUITE 2
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-3493
Practice Address - Country:US
Practice Address - Phone:960-496-9851
Practice Address - Fax:860-482-4047
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2013-06-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CT006526225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004209723Medicaid
CT080006526CT01OtherANTHEM BCBS
CT080006526CT01OtherANTHEM BCBS