Provider Demographics
NPI:1063962116
Name:WIGGLE WORMS PEDIATRIC PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:WIGGLE WORMS PEDIATRIC PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BASTEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-351-3078
Mailing Address - Street 1:764 US ROUTE 1
Mailing Address - Street 2:UNIT 4
Mailing Address - City:YORK
Mailing Address - State:ME
Mailing Address - Zip Code:03909-5883
Mailing Address - Country:US
Mailing Address - Phone:207-351-3083
Mailing Address - Fax:207-351-3083
Practice Address - Street 1:764 US ROUTE 1
Practice Address - Street 2:UNIT 4
Practice Address - City:YORK
Practice Address - State:ME
Practice Address - Zip Code:03909-5883
Practice Address - Country:US
Practice Address - Phone:207-351-3083
Practice Address - Fax:207-351-3083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-12
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP2587235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty