Healthcare Provider Details

I. General information

NPI: 1770600975
Provider Name (Legal Business Name): TINA LYNN FOX PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 05/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

158 ROSS RD
KENNEBUNK ME
04043-6532
US

IV. Provider business mailing address

465 MAIN ST APT 103
SPRINGVALE ME
04083-1809
US

V. Phone/Fax

Practice location:
  • Phone: 207-604-7147
  • Fax:
Mailing address:
  • Phone: 207-608-8002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPA3179
License Number StateME

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierPA3179
Identifier TypeOTHER
Identifier StateME
Identifier IssuerPTA LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: