Provider Demographics
NPI:1396775383
Name:TARDIF, DANA PAUL (PT ; LMT)
Entity type:Individual
Prefix:MR
First Name:DANA
Middle Name:PAUL
Last Name:TARDIF
Suffix:
Gender:M
Credentials:PT ; LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 227
Mailing Address - Street 2:11 MAIN ROAD NORTH
Mailing Address - City:HAMPDEN
Mailing Address - State:ME
Mailing Address - Zip Code:04444-0227
Mailing Address - Country:US
Mailing Address - Phone:207-862-3906
Mailing Address - Fax:207-862-2892
Practice Address - Street 1:11 MAIN ROAD NORTH
Practice Address - Street 2:
Practice Address - City:HAMPDEN
Practice Address - State:ME
Practice Address - Zip Code:04444-0227
Practice Address - Country:US
Practice Address - Phone:207-862-3906
Practice Address - Fax:207-862-2892
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT532225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME252020099Medicaid
VX2222Medicare PIN