Provider Demographics
NPI:1396214300
Name:MAINS, DIANA (LMT)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:MAINS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 JOE BERRY RD
Mailing Address - Street 2:
Mailing Address - City:CORNISH
Mailing Address - State:ME
Mailing Address - Zip Code:04020-3720
Mailing Address - Country:US
Mailing Address - Phone:207-310-3897
Mailing Address - Fax:
Practice Address - Street 1:31 MAPLE ST
Practice Address - Street 2:
Practice Address - City:CORNISH
Practice Address - State:ME
Practice Address - Zip Code:04020-3101
Practice Address - Country:US
Practice Address - Phone:207-619-0994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT5477225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist