Provider Demographics
NPI:1508456054
Name:DORIAN, TRACEY (LMT, CPMT)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:DORIAN
Suffix:
Gender:F
Credentials:LMT, CPMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 ROUTE 133
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:ME
Mailing Address - Zip Code:04364-4019
Mailing Address - Country:US
Mailing Address - Phone:207-446-5257
Mailing Address - Fax:
Practice Address - Street 1:220B ROUTE 133
Practice Address - Street 2:
Practice Address - City:WINTHROP
Practice Address - State:ME
Practice Address - Zip Code:04364-4019
Practice Address - Country:US
Practice Address - Phone:207-446-5257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT6166225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist