Provider Demographics
NPI:1689301822
Name:ANDERSON, MARY E
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GREAT BROOK DR
Mailing Address - Street 2:
Mailing Address - City:ORONO
Mailing Address - State:ME
Mailing Address - Zip Code:04473-3065
Mailing Address - Country:US
Mailing Address - Phone:207-852-0122
Mailing Address - Fax:
Practice Address - Street 1:1365 BROADWAY
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-2401
Practice Address - Country:US
Practice Address - Phone:207-942-2233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT6314225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist