Provider Demographics
NPI:1457344590
Name:DESAUTELS, JOEL A (MPT ATC)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:A
Last Name:DESAUTELS
Suffix:
Gender:M
Credentials:MPT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 NICHOLS RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VT
Mailing Address - Zip Code:05454-9614
Mailing Address - Country:US
Mailing Address - Phone:802-849-0202
Mailing Address - Fax:
Practice Address - Street 1:426 INDUSTRIAL AVE
Practice Address - Street 2:SUITE 190
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-4448
Practice Address - Country:US
Practice Address - Phone:802-860-4360
Practice Address - Fax:802-488-3160
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040-0003725225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist