Provider Demographics
NPI:1861163123
Name:CHARLES, SYDNEY GRACE (DPT)
Entity type:Individual
Prefix:
First Name:SYDNEY
Middle Name:GRACE
Last Name:CHARLES
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 ENTERPRISE DRIVE
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-4239
Mailing Address - Country:US
Mailing Address - Phone:207-890-4304
Mailing Address - Fax:
Practice Address - Street 1:1 ENTERPRISE DRIVE
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-4239
Practice Address - Country:US
Practice Address - Phone:207-951-3373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-25
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT5967225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEPT5967Medicaid