Provider Demographics
NPI:1619633401
Name:PANTOS, POLYXENIA J (OTD)
Entity Type:Individual
Prefix:
First Name:POLYXENIA
Middle Name:J
Last Name:PANTOS
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 HALL ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3315
Mailing Address - Country:US
Mailing Address - Phone:617-435-0744
Mailing Address - Fax:
Practice Address - Street 1:484 MAIN ST STE 600
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1881
Practice Address - Country:US
Practice Address - Phone:800-244-2756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-16
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA13707225X00000X
MEOT4102225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist