Healthcare Provider Details

I. General information

NPI: 1295904811
Provider Name (Legal Business Name): LAURA RUTH SUGRUE MSPT, OCS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2008
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1068 MAIN ST STE A
SANFORD ME
04073-3792
US

IV. Provider business mailing address

313 PEASE RD
BUXTON ME
04093-6516
US

V. Phone/Fax

Practice location:
  • Phone: 207-324-6789
  • Fax: 844-292-4021
Mailing address:
  • Phone: 585-748-9541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT3363
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: