Provider Demographics
NPI:1235754193
Name:FORTIN, MAURA (PTA)
Entity Type:Individual
Prefix:MS
First Name:MAURA
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 1:22 HARDIE CT
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28792-0104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4687 BOYLSTON HWY
Practice Address - Street 2:
Practice Address - City:MILLS RIVER
Practice Address - State:NC
Practice Address - Zip Code:28759-6731
Practice Address - Country:US
Practice Address - Phone:828-890-0040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-16
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA7078225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant