Provider Demographics
NPI:1366727703
Name:PROULX, DAVID (LMT)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:PROULX
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 173
Mailing Address - Street 2:
Mailing Address - City:GROSVENOR DALE
Mailing Address - State:CT
Mailing Address - Zip Code:06246-0173
Mailing Address - Country:US
Mailing Address - Phone:508-963-0014
Mailing Address - Fax:
Practice Address - Street 1:140 WORCESTER ST
Practice Address - Street 2:SUITE 9
Practice Address - City:WEST BOYLSTON
Practice Address - State:MA
Practice Address - Zip Code:01583-1765
Practice Address - Country:US
Practice Address - Phone:508-963-0014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9477225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9477OtherMASSAGE THERAPIST