Provider Demographics
NPI:1649234816
Name:DESLAURIERS, DOMINICK EDWARD (PT)
Entity Type:Individual
Prefix:MR
First Name:DOMINICK
Middle Name:EDWARD
Last Name:DESLAURIERS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:693 BLOOMFIELD AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-2489
Mailing Address - Country:US
Mailing Address - Phone:860-242-8427
Mailing Address - Fax:860-242-4147
Practice Address - Street 1:693 BLOOMFIELD AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-2489
Practice Address - Country:US
Practice Address - Phone:860-242-8427
Practice Address - Fax:860-242-4147
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT4979225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT080004979CT04OtherANTHEM BC/BS