Provider Demographics
NPI:1043691777
Name:FORTIN, CHRISTINE (PTA)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:FORTIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 WALLY LN
Mailing Address - Street 2:
Mailing Address - City:BERWICK
Mailing Address - State:ME
Mailing Address - Zip Code:03901-2459
Mailing Address - Country:US
Mailing Address - Phone:207-698-5026
Mailing Address - Fax:
Practice Address - Street 1:3 WALLY LN
Practice Address - Street 2:
Practice Address - City:BERWICK
Practice Address - State:ME
Practice Address - Zip Code:03901-2459
Practice Address - Country:US
Practice Address - Phone:207-698-5026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0256225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant