Provider Demographics
NPI:1093814485
Name:TUCKER, BETHANY L (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:L
Last Name:TUCKER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:L
Other - Last Name:PERRIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:100 ST LOUIS AVE
Mailing Address - Street 2:
Mailing Address - City:HERMON
Mailing Address - State:ME
Mailing Address - Zip Code:04401-0874
Mailing Address - Country:US
Mailing Address - Phone:207-991-7412
Mailing Address - Fax:866-220-5031
Practice Address - Street 1:840 HAMMOND ST STE 2
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4339
Practice Address - Country:US
Practice Address - Phone:207-433-7778
Practice Address - Fax:866-220-5031
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT3176225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEPT3176OtherPT LICENSE
MEP00369309OtherRAILROAD MEDICARE
ME099276OtherBLUE CROSS & BLUE SHIELD
MEPT3176OtherPT LICENSE
ME099276OtherBLUE CROSS & BLUE SHIELD