Provider Demographics
NPI:1114385036
Name:RODERIGUE, MIRIAH
Entity Type:Individual
Prefix:
First Name:MIRIAH
Middle Name:
Last Name:RODERIGUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 GRIMMAULD PL
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:ME
Mailing Address - Zip Code:04330-2656
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:188 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-5928
Practice Address - Country:US
Practice Address - Phone:207-622-3121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-05
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA4066225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant