Provider Demographics
NPI:1568658466
Name:STREETER, JOANNA G (PT)
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:G
Last Name:STREETER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 WALLACE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-6143
Mailing Address - Country:US
Mailing Address - Phone:207-761-0650
Mailing Address - Fax:
Practice Address - Street 1:272 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-3637
Practice Address - Country:US
Practice Address - Phone:207-874-2466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT2161225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME000842401Medicare PIN