Healthcare Provider Details

I. General information

NPI: 1154583391
Provider Name (Legal Business Name): RENEE MARIE MORAN P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 BANGOR MALL BLVD UNIT D-1
BANGOR ME
04401-3612
US

IV. Provider business mailing address

22 ALLISON PARK
BREWER ME
04412-1350
US

V. Phone/Fax

Practice location:
  • Phone: 207-291-5714
  • Fax: 207-433-1246
Mailing address:
  • Phone: 207-989-0608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT2729
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: