Provider Demographics
NPI:1356077929
Name:GAUTREAU, ROBERT C (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:C
Last Name:GAUTREAU
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:262 SHORE AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:TICONDEROGA
Mailing Address - State:NY
Mailing Address - Zip Code:12883-2907
Mailing Address - Country:US
Mailing Address - Phone:518-207-5488
Mailing Address - Fax:518-585-3263
Practice Address - Street 1:262 SHORE AIRPORT RD
Practice Address - Street 2:
Practice Address - City:TICONDEROGA
Practice Address - State:NY
Practice Address - Zip Code:12883-2907
Practice Address - Country:US
Practice Address - Phone:518-207-5488
Practice Address - Fax:518-585-3263
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-26
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012163-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist