Provider Demographics
NPI:1407101777
Name:STEWART, MARISSA DEAN (DPT)
Entity Type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:DEAN
Last Name:STEWART
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 FODEN RD WEST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2327
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:207-874-1483
Practice Address - Street 1:100 FODEN RD WEST
Practice Address - Street 2:SUITE 205
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2327
Practice Address - Country:US
Practice Address - Phone:207-828-0361
Practice Address - Fax:207-874-1483
Is Sole Proprietor?:No
Enumeration Date:2012-07-23
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT3917225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME002881001Medicare PIN