Healthcare Provider Details

I. General information

NPI: 1417103631
Provider Name (Legal Business Name): MELISSA D RAYMOND PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2008
Last Update Date: 01/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 UNION ST SUITE 3
BANGOR ME
04401-3060
US

IV. Provider business mailing address

1012 UNION ST SUITE 3
BANGOR ME
04401-3060
US

V. Phone/Fax

Practice location:
  • Phone: 207-404-8100
  • Fax: 207-990-1248
Mailing address:
  • Phone: 207-404-8100
  • Fax: 207-990-1248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT3438
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: