Provider Demographics
NPI:1013568617
Name:SUKIENNIK, RICHARD ADAM (DPT)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ADAM
Last Name:SUKIENNIK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:758 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-3224
Mailing Address - Country:US
Mailing Address - Phone:207-941-8400
Mailing Address - Fax:207-990-1745
Practice Address - Street 1:758 BROADWAY
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3224
Practice Address - Country:US
Practice Address - Phone:207-941-8400
Practice Address - Fax:207-990-1745
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-25
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT5179225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist