Provider Demographics
NPI:1851678064
Name:LATENDRESSE, MARY ELIZABETH (LMT)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELIZABETH
Last Name:LATENDRESSE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 PREBLE ST
Mailing Address - Street 2:APT 553
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-4936
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:218 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2632
Practice Address - Country:US
Practice Address - Phone:207-773-5778
Practice Address - Fax:207-773-5773
Is Sole Proprietor?:No
Enumeration Date:2011-11-16
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT2239174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist