Healthcare Provider Details

I. General information

NPI: 1841997137
Provider Name (Legal Business Name): CAROLYN VIRGINIA MENGES DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2023
Last Update Date: 02/08/2023
Certification Date: 02/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 CONGRESS ST
PORTLAND ME
04102-2102
US

IV. Provider business mailing address

33 ROBERTS ST APT 3
PORTLAND ME
04102-2880
US

V. Phone/Fax

Practice location:
  • Phone: 207-774-5710
  • Fax:
Mailing address:
  • Phone: 440-478-9543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT6455
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: