Healthcare Provider Details

I. General information

NPI: 1649280637
Provider Name (Legal Business Name): PEDIATRIC PHYSICAL THERAPY CONNECTION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 02/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 US ROUTE ONE SUITE 180
FALMOUTH ME
04105
US

IV. Provider business mailing address

PO BOX 66821
FALMOUTH ME
04105-6821
US

V. Phone/Fax

Practice location:
  • Phone: 207-781-5369
  • Fax: 207-781-5862
Mailing address:
  • Phone: 207-781-5369
  • Fax: 207-781-5862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT0512
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License NumberC15212
License Number StateME
# 3
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberC15212
License Number StateMD

VIII. Authorized Official

Name: MS. BRENDA MATTSON
Title or Position: OWNER PHYSICAL THERAPIST ORTHOTIST
Credential: PT BOCO
Phone: 207-781-5369