Healthcare Provider Details

I. General information

NPI: 1083633002
Provider Name (Legal Business Name): TIMOTHY LEE WAKELAND MSPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 COMMERCE PARK
ELLSWORTH ME
04605-3383
US

IV. Provider business mailing address

37 COMMERCE PARK
ELLSWORTH ME
04605-3383
US

V. Phone/Fax

Practice location:
  • Phone: 207-667-2422
  • Fax: 207-667-0135
Mailing address:
  • Phone: 207-667-2422
  • Fax: 207-667-0135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPT1167
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: