Provider Demographics
NPI:1174867576
Name:SOUTHERN MAINE PEDIATRIC THERAPIES, PLLC
Entity Type:Organization
Organization Name:SOUTHERN MAINE PEDIATRIC THERAPIES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSANNE
Authorized Official - Middle Name:L
Authorized Official - Last Name:MARTORANO
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:207-233-7373
Mailing Address - Street 1:14 MURRAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:GORHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04038
Mailing Address - Country:US
Mailing Address - Phone:207-233-7373
Mailing Address - Fax:888-731-2721
Practice Address - Street 1:14 MURRAY DRIVE
Practice Address - Street 2:
Practice Address - City:GORHAM
Practice Address - State:ME
Practice Address - Zip Code:04038
Practice Address - Country:US
Practice Address - Phone:207-233-7373
Practice Address - Fax:888-731-2721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT1187225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1467595322OtherINDIVIDUAL NPI