Provider Demographics
NPI:1932156361
Name:PTAK, AIMEE JEANNE (DPT)
Entity Type:Individual
Prefix:MS
First Name:AIMEE
Middle Name:JEANNE
Last Name:PTAK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MISS
Other - First Name:AIMEE
Other - Middle Name:JEANNE
Other - Last Name:DALLAIRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:42 COOLIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02452-5744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:42 COOLIDGE AVE
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02452-5744
Practice Address - Country:US
Practice Address - Phone:781-929-5688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2012-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT01487225100000X
MA13214225100000X
CA36802225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI26564-9OtherBCBS
RI406542OtherBLUE CHIP
RI007010688Medicare ID - Type Unspecified