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General NPI Number Information
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NPI Number | 1215333554
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Entity Type | Organization
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Legal Business Name | PERFORMANCE PHYSICAL THERAPY AND SPORTS REHAB INC.
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Dates
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Enumeration Date | 11/14/2014
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Last Update Date | 11/14/2014
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Provider Practice Location Address
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Address Line | 277 STATE ST SUITE 1B
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City | BANGOR
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State | ME
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Zip | 04401-5439
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Country | US
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Telephone | 207-356-9810
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Fax |
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Provider Business Mailing Address
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Address Line | 95 SUNSET STRIP
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City | BREWER
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State | ME
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Zip | 04412-1632
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO/PHYSICAL THERAPIST
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Name | BRADLEY LAWRENCE LIBBY
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Credential | PT, DPT
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Telephone | 207-356-9810
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT4035
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License Number State | ME
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