Provider Demographics
NPI:1104209139
Name:SOULE-REGINE, ALEXANDER
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:SOULE-REGINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 AUSTIN DR
Mailing Address - Street 2:APT 2
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-5413
Mailing Address - Country:US
Mailing Address - Phone:978-846-7097
Mailing Address - Fax:
Practice Address - Street 1:60 AUSTIN DR
Practice Address - Street 2:APT 2
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-5413
Practice Address - Country:US
Practice Address - Phone:978-846-7097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT104.01128232255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer