Provider Demographics
NPI:1952973398
Name:LYCETTE, MARANDA L
Entity Type:Individual
Prefix:
First Name:MARANDA
Middle Name:L
Last Name:LYCETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 FERRY RD
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:ME
Mailing Address - Zip Code:04250-6235
Mailing Address - Country:US
Mailing Address - Phone:207-577-2456
Mailing Address - Fax:
Practice Address - Street 1:102 CAMPUS AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-6019
Practice Address - Country:US
Practice Address - Phone:207-777-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA5541225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant