Provider Demographics
NPI:1922173855
Name:WIGGLE WORMS PEDIATRIC PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:WIGGLE WORMS PEDIATRIC PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KERI
Authorized Official - Middle Name:A
Authorized Official - Last Name:STOORZA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:207-351-3078
Mailing Address - Street 1:10 MARKET PLACE DR
Mailing Address - Street 2:UNIT 3B
Mailing Address - City:YORK
Mailing Address - State:ME
Mailing Address - Zip Code:03909
Mailing Address - Country:US
Mailing Address - Phone:207-351-3078
Mailing Address - Fax:207-351-3083
Practice Address - Street 1:10 MARKET PLACE DR
Practice Address - Street 2:UNIT 3B
Practice Address - City:YORK
Practice Address - State:ME
Practice Address - Zip Code:03909
Practice Address - Country:US
Practice Address - Phone:207-351-3078
Practice Address - Fax:207-351-3083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT2283225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432325200Medicaid
NH30394489Medicaid