Provider Demographics
NPI:1013076439
Name:DESTEFANO TAIT, JUNE C (PT)
Entity type:Individual
Prefix:
First Name:JUNE
Middle Name:C
Last Name:DESTEFANO TAIT
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 1:51 US ROUTE 1
Mailing Address - Street 2:SUITE J
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-7158
Mailing Address - Country:US
Mailing Address - Phone:207-883-1227
Mailing Address - Fax:207-883-6199
Practice Address - Street 1:51 US ROUTE 1
Practice Address - Street 2:SUITE J
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-7158
Practice Address - Country:US
Practice Address - Phone:207-883-1227
Practice Address - Fax:207-883-6199
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT940225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
QX9576OtherMEDICARE PTAN
ME013890OtherANTHEM
ME278030099Medicaid
ME650009113OtherRR MEDICARE