Provider Demographics
NPI:1316580491
Name:FOLSOM, ALEXANDER RICKY (PTA, ATC)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:RICKY
Last Name:FOLSOM
Suffix:
Gender:M
Credentials:PTA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 BANGOR ST STE A
Mailing Address - Street 2:
Mailing Address - City:HOULTON
Mailing Address - State:ME
Mailing Address - Zip Code:04730-1603
Mailing Address - Country:US
Mailing Address - Phone:207-521-0200
Mailing Address - Fax:207-521-0210
Practice Address - Street 1:98 BANGOR ST STE A
Practice Address - Street 2:
Practice Address - City:HOULTON
Practice Address - State:ME
Practice Address - Zip Code:04730-1603
Practice Address - Country:US
Practice Address - Phone:207-521-0200
Practice Address - Fax:207-521-0210
Is Sole Proprietor?:No
Enumeration Date:2019-10-22
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAT7492255A2300X
MEPA5638225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer