Provider Demographics
NPI:1417356940
Name:BERUBE, JULIE R (DPT)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:R
Last Name:BERUBE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7687 FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:NY
Mailing Address - Zip Code:13039-8921
Mailing Address - Country:US
Mailing Address - Phone:315-635-5000
Mailing Address - Fax:315-446-1816
Practice Address - Street 1:6800 E GENESEE ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1089
Practice Address - Country:US
Practice Address - Phone:315-635-5000
Practice Address - Fax:315-446-1816
Is Sole Proprietor?:No
Enumeration Date:2014-08-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038140225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04323864Medicaid