Provider Demographics
NPI:1417302910
Name:HERRICK, PHILOMENA (LMT)
Entity Type:Individual
Prefix:
First Name:PHILOMENA
Middle Name:
Last Name:HERRICK
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 1:597 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-5412
Mailing Address - Country:US
Mailing Address - Phone:207-774-7242
Mailing Address - Fax:207-871-8041
Practice Address - Street 1:597 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-5412
Practice Address - Country:US
Practice Address - Phone:207-774-7242
Practice Address - Fax:207-871-8041
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-03
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT 2181225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist