Healthcare Provider Details

I. General information

NPI: 1245974708
Provider Name (Legal Business Name): MICHELLE FORBES SUMMERVILLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2022
Last Update Date: 04/21/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

COASTAL KIDS OT 1222 PORTLAND RD
ARUNDEL ME
04046
US

IV. Provider business mailing address

77 ROBERTS POND RD
LYMAN ME
04002-6714
US

V. Phone/Fax

Practice location:
  • Phone: 207-337-1058
  • Fax:
Mailing address:
  • Phone: 207-544-3925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License NumberPA4434
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: