Provider Demographics
NPI:1285639534
Name:DANIELSON, GARTH WARD (PT)
Entity type:Individual
Prefix:MR
First Name:GARTH
Middle Name:WARD
Last Name:DANIELSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:ME
Mailing Address - Zip Code:04952-3113
Mailing Address - Country:US
Mailing Address - Phone:207-322-6243
Mailing Address - Fax:
Practice Address - Street 1:404 STATE ST
Practice Address - Street 2:STE 400
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6623
Practice Address - Country:US
Practice Address - Phone:207-942-7630
Practice Address - Fax:207-942-5686
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT2906225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEDAME1340Medicare ID - Type UnspecifiedMEDICARE ID#