Provider Demographics
NPI:1962891390
Name:SOUTHERN MAINE PEDIATRIC THERAPIES
Entity type:Organization
Organization Name:SOUTHERN MAINE PEDIATRIC THERAPIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTORANO
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:207-233-7373
Mailing Address - Street 1:57 TANDBERG TRL
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04062-6425
Mailing Address - Country:US
Mailing Address - Phone:207-233-7373
Mailing Address - Fax:
Practice Address - Street 1:57 TANDBERG TRL
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:ME
Practice Address - Zip Code:04062-6425
Practice Address - Country:US
Practice Address - Phone:207-233-7373
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT2888252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency