Provider Demographics
NPI:1649538653
Name:SEAGRAVE, RONALD J
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:J
Last Name:SEAGRAVE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 SUMMIT CIR
Mailing Address - Street 2:
Mailing Address - City:ELLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06029-3897
Mailing Address - Country:US
Mailing Address - Phone:401-743-8603
Mailing Address - Fax:
Practice Address - Street 1:9 SUMMIT CIR
Practice Address - Street 2:
Practice Address - City:ELLINGTON
Practice Address - State:CT
Practice Address - Zip Code:06029-3897
Practice Address - Country:US
Practice Address - Phone:401-743-8603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-26
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8627225200000X
RIPTA00847225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant