Healthcare Provider Details

I. General information

NPI: 1326209214
Provider Name (Legal Business Name): NICOLE DENISE DESJARDINS MSPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 MINOT AVE
AUBURN ME
04210-4332
US

IV. Provider business mailing address

18 CARON ST
LEWISTON ME
04240-6446
US

V. Phone/Fax

Practice location:
  • Phone: 207-784-3573
  • Fax:
Mailing address:
  • Phone: 207-795-6330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License NumberPT2877
License Number StateME

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: