Provider Demographics
NPI:1407881584
Name:CHARLEBOIS, NANCY (PT)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:CHARLEBOIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 FORE ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101
Mailing Address - Country:US
Mailing Address - Phone:207-773-5778
Mailing Address - Fax:207-773-5773
Practice Address - Street 1:100 FORE ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101
Practice Address - Country:US
Practice Address - Phone:207-773-5778
Practice Address - Fax:207-773-5773
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT2432225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
047653OtherANTHEM
ME415760099Medicaid
7238588OtherAETNA
ME432865500OtherMAINECARE
047653OtherANTHEM
ME000303601Medicare PIN