Provider Demographics
NPI:1336370436
Name:DEARBORN, MOLLY (PTA)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:DEARBORN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:
Other - Last Name:DAIGLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:764 US ROUTE 1 #4
Mailing Address - Street 2:WIGGLE WORMS PEDIATRIC PT
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 1:764 US ROUTE 1
Practice Address - Street 2:#4
Practice Address - City:YORK
Practice Address - State:ME
Practice Address - Zip Code:03909-1680
Practice Address - Country:US
Practice Address - Phone:207-351-3078
Practice Address - Fax:207-351-3083
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-06
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA3564225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant