Provider Demographics
NPI:1407134281
Name:LEARY, CHARLOTTE RAINS
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:RAINS
Last Name:LEARY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHARLOTTE
Other - Middle Name:RAINS
Other - Last Name:FAIRCLOTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:55 CONGRESS AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:BATH
Mailing Address - State:ME
Mailing Address - Zip Code:04530-1536
Mailing Address - Country:US
Mailing Address - Phone:207-846-8725
Mailing Address - Fax:207-846-8728
Practice Address - Street 1:100 BRICKHILL AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-1999
Practice Address - Country:US
Practice Address - Phone:207-879-7510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-28
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT3853225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist