Provider Demographics
NPI:1790776540
Name:STOUT, CHRISTY LANE (PT)
Entity Type:Individual
Prefix:MS
First Name:CHRISTY
Middle Name:LANE
Last Name:STOUT
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 1:760 UNION STREET
Mailing Address - Street 2:PINE TREE PHYSICAL THERAPY
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401
Mailing Address - Country:US
Mailing Address - Phone:207-942-2266
Mailing Address - Fax:207-942-7577
Practice Address - Street 1:760 UNION STREET
Practice Address - Street 2:PINE TREE PHYSICAL THERAPY
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401
Practice Address - Country:US
Practice Address - Phone:207-942-2266
Practice Address - Fax:207-942-7577
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME848225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MESTMM8064Medicare ID - Type Unspecified