Healthcare Provider Details

I. General information

NPI: 1700296910
Provider Name (Legal Business Name): MARY E FONTAINE, MS, RPT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2014
Last Update Date: 04/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

654 WALLIS RD
RYE NH
03870-2245
US

IV. Provider business mailing address

654 WALLIS RD
RYE NH
03870-2245
US

V. Phone/Fax

Practice location:
  • Phone: 603-964-8819
  • Fax:
Mailing address:
  • Phone: 603-964-8819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License NumberPT #0188
License Number StateNH

VIII. Authorized Official

Name: MRS. MARY E FONTAINE
Title or Position: PEDIATRIC PHYSICAL THERAPIST
Credential: MS, RPT
Phone: 603-964-8819