Provider Demographics
NPI:1598919391
Name:DESSUREAU, CAROLYN BAUMAN (PT)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:BAUMAN
Last Name:DESSUREAU
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05676-1579
Mailing Address - Country:US
Mailing Address - Phone:802-244-1140
Mailing Address - Fax:
Practice Address - Street 1:137 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:VT
Practice Address - Zip Code:05676-1579
Practice Address - Country:US
Practice Address - Phone:802-244-1140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-06
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040-0003114225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist