Provider Demographics
NPI:1770453169
Name:THRALL, MARK KENNETH (AA, LMT, OTA)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:KENNETH
Last Name:THRALL
Suffix:
Gender:M
Credentials:AA, LMT, OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 MELDEN DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-9541
Mailing Address - Country:US
Mailing Address - Phone:207-939-4872
Mailing Address - Fax:
Practice Address - Street 1:36 MELDEN DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-9541
Practice Address - Country:US
Practice Address - Phone:207-939-4872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-10
Last Update Date:2025-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT5860225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty