Provider Demographics
NPI:1518689959
Name:TAVARES, MADISON DIANE (PT)
Entity Type:Individual
Prefix:DR
First Name:MADISON
Middle Name:DIANE
Last Name:TAVARES
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 1:723 RIVERSIDE ST APT 215
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-5931
Mailing Address - Country:US
Mailing Address - Phone:781-947-6556
Mailing Address - Fax:
Practice Address - Street 1:65 PORTLAND RD STE B
Practice Address - Street 2:
Practice Address - City:KENNEBUNK
Practice Address - State:ME
Practice Address - Zip Code:04043-6742
Practice Address - Country:US
Practice Address - Phone:207-439-5104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT6321225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist