Healthcare Provider Details

I. General information

NPI: 1497414890
Provider Name (Legal Business Name): AMY ST. PETER PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY WATERMAN PT

II. Dates (important events)

Enumeration Date: 12/13/2021
Last Update Date: 12/13/2021
Certification Date: 12/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 STILLWATER AVE
OLD TOWN ME
04468-2215
US

IV. Provider business mailing address

79 POPLAR ST
BANGOR ME
04401-3416
US

V. Phone/Fax

Practice location:
  • Phone: 207-817-0214
  • Fax:
Mailing address:
  • Phone: 207-478-4458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT1745
License Number StateME

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: