Provider Demographics
NPI:1780891481
Name:SMALL, STEPHEN RAYMOND (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:RAYMOND
Last Name:SMALL
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
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Mailing Address - Street 1:75 WASHINGTON AVE
Mailing Address - Street 2:STE 300
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2665
Mailing Address - Country:US
Mailing Address - Phone:207-761-8402
Mailing Address - Fax:207-761-8405
Practice Address - Street 1:26 PORTLAND STREET
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101
Practice Address - Country:US
Practice Address - Phone:207-761-8402
Practice Address - Fax:207-761-8405
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2017-12-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MEPT1506225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME061343OtherANTHEM
ME061343OtherANTHEM