Provider Demographics
NPI:1770600975
Name:FOX, TINA LYNN (PTA)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:LYNN
Last Name:FOX
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 MAIN ST APT 103
Mailing Address - Street 2:
Mailing Address - City:SPRINGVALE
Mailing Address - State:ME
Mailing Address - Zip Code:04083-1809
Mailing Address - Country:US
Mailing Address - Phone:207-608-8002
Mailing Address - Fax:
Practice Address - Street 1:158 ROSS RD
Practice Address - Street 2:
Practice Address - City:KENNEBUNK
Practice Address - State:ME
Practice Address - Zip Code:04043-6532
Practice Address - Country:US
Practice Address - Phone:207-604-7147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA3179225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEPA3179OtherPTA LICENSE