Provider Demographics
NPI:1134137490
Name:WAKELAND PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:WAKELAND PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WAKELAND
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:207-667-4278
Mailing Address - Street 1:248 STATE STREET
Mailing Address - Street 2:SUITE 3A
Mailing Address - City:ELLSWORTH
Mailing Address - State:ME
Mailing Address - Zip Code:04605
Mailing Address - Country:US
Mailing Address - Phone:207-667-4278
Mailing Address - Fax:207-667-4279
Practice Address - Street 1:248 STATE ST
Practice Address - Street 2:SUITE 3A
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605-1850
Practice Address - Country:US
Practice Address - Phone:207-667-4278
Practice Address - Fax:207-667-4279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT 1167174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty