Provider Demographics
NPI:1346744216
Name:ATHLETIC EVOLUTION PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:ATHLETIC EVOLUTION PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEFANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUSSELLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-935-7701
Mailing Address - Street 1:78C OLYMPIA AVE
Mailing Address - Street 2:
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-2057
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:78C OLYMPIA AVE
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-2057
Practice Address - Country:US
Practice Address - Phone:781-935-7701
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-23
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy