Provider Demographics
NPI:1972056729
Name:RHEAULT, IAN MATTHEW (DPT)
Entity type:Individual
Prefix:MR
First Name:IAN
Middle Name:MATTHEW
Last Name:RHEAULT
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 NW 12TH AVE
Mailing Address - Street 2:SUITE 1301
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1003
Mailing Address - Country:US
Mailing Address - Phone:305-689-5635
Mailing Address - Fax:305-689-5930
Practice Address - Street 1:1400 NW 12TH AVE
Practice Address - Street 2:SUITE 1301
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1003
Practice Address - Country:US
Practice Address - Phone:305-689-5635
Practice Address - Fax:305-689-5930
Is Sole Proprietor?:No
Enumeration Date:2016-07-28
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT31686225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist