Individual
RAVEN R FULFORD
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PT
Contact information
Practice address
55 SPRING STREET, SCARBOROUGH, ME 04074
(207) 396-7337
(207) 885-4349
Mailing address
190 RIVERSIDE ST, SUITE 6B, PORTLAND, ME 04103-1073
(207) 661-2000
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
PT4184
ME
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
E400360799
—
ME
Enumeration date
01/05/2017
Last updated
02/27/2018
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