Healthcare Provider Details

I. General information

NPI: 1710193040
Provider Name (Legal Business Name): TAMMY ANNE PELLEGRINO OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CUMBERLAND PL SUITE 108
BANGOR ME
04401-5083
US

IV. Provider business mailing address

PO BOX 3143
BREWER ME
04412-3143
US

V. Phone/Fax

Practice location:
  • Phone: 207-900-9000
  • Fax: 207-945-8645
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT519
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: