Provider Demographics
NPI:1285792408
Name:VILLENEUVE, WAYNE (PT)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:VILLENEUVE
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 1:277 BLAIR PARK ROAD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495
Mailing Address - Country:US
Mailing Address - Phone:802-878-3600
Mailing Address - Fax:802-879-3041
Practice Address - Street 1:277 BLAIR PARK ROAD
Practice Address - Street 2:SUITE 110
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495
Practice Address - Country:US
Practice Address - Phone:802-878-3600
Practice Address - Fax:802-879-3041
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040-0003658225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT00068910OtherBCBS
VT389334OtherMVP
VT065-68910Medicare ID - Type Unspecified