Provider Demographics
NPI:1841763182
Name:BERUBE, MACEY NICOLE (DPT)
Entity Type:Individual
Prefix:
First Name:MACEY
Middle Name:NICOLE
Last Name:BERUBE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 MAIN ST
Mailing Address - Street 2:DEPT OF PHYSICAL THERAPY
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-7041
Mailing Address - Country:US
Mailing Address - Phone:207-795-0111
Mailing Address - Fax:
Practice Address - Street 1:300 MAIN ST
Practice Address - Street 2:DEPT OF PHYSICAL THERAPY
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7041
Practice Address - Country:US
Practice Address - Phone:207-795-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT5200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist