Provider Demographics
NPI:1699279661
Name:DUBOIS, REYNOLD JOSEPH (PT)
Entity type:Individual
Prefix:
First Name:REYNOLD
Middle Name:JOSEPH
Last Name:DUBOIS
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 1:85 HUDSON RD
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-2010
Mailing Address - Country:US
Mailing Address - Phone:207-249-8038
Mailing Address - Fax:
Practice Address - Street 1:85 HUDSON RD
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-2010
Practice Address - Country:US
Practice Address - Phone:207-249-8038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-22
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT444225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty