Provider Demographics
NPI:1205907474
Name:LEPAGE, MICHAEL PAUL (MSPT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:PAUL
Last Name:LEPAGE
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:377 N MAIN ST APT 2
Mailing Address - Street 2:
Mailing Address - City:NAUGATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06770-3228
Mailing Address - Country:US
Mailing Address - Phone:203-687-9384
Mailing Address - Fax:
Practice Address - Street 1:900 STRAITS TPKE
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:CT
Practice Address - Zip Code:06762-2800
Practice Address - Country:US
Practice Address - Phone:203-577-5325
Practice Address - Fax:203-577-5329
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006972225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT080006972CT06OtherBCBS ID #
CT076583Medicare ID - Type Unspecified