Provider Demographics
NPI:1619551967
Name:COGBURN, CULLEN VALIER
Entity Type:Individual
Prefix:
First Name:CULLEN
Middle Name:VALIER
Last Name:COGBURN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 EMERSON ST APT 2
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-3294
Mailing Address - Country:US
Mailing Address - Phone:828-545-6346
Mailing Address - Fax:
Practice Address - Street 1:449 COTTAGE RD
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-4924
Practice Address - Country:US
Practice Address - Phone:207-799-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-11
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist