Healthcare Provider Details

I. General information

NPI: 1538410972
Provider Name (Legal Business Name): SHOBHA CHETTY ED.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 FEDERAL ST
BRUNSWICK ME
04011-2125
US

IV. Provider business mailing address

3 GLOVER ST
BRUNSWICK ME
04011-7407
US

V. Phone/Fax

Practice location:
  • Phone: 207-319-1900
  • Fax:
Mailing address:
  • Phone: 207-406-2526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number37-
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: