Provider Demographics
NPI:1477509115
Name:CREDIT, LEO R JR (PT)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:R
Last Name:CREDIT
Suffix:JR
Gender:M
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:PO BOX 1047
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:ME
Mailing Address - Zip Code:04039-1047
Mailing Address - Country:US
Mailing Address - Phone:207-657-5600
Mailing Address - Fax:207-657-5620
Practice Address - Street 1:6 TURNPIKE ACRES RD
Practice Address - Street 2:
Practice Address - City:GRAY
Practice Address - State:ME
Practice Address - Zip Code:04039-9432
Practice Address - Country:US
Practice Address - Phone:207-657-5600
Practice Address - Fax:207-657-5620
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT1116225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MM8926Medicare ID - Type Unspecified