Healthcare Provider Details

I. General information

NPI: 1699925339
Provider Name (Legal Business Name): BONNIE G DUBAY-BRENNAN LMT NCTMB
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2008
Last Update Date: 09/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 BRIDGE ST
BUCKSPORT ME
04416-4087
US

IV. Provider business mailing address

PO BOX 1002 12 BRIDGE ST.
BUCKSPORT ME
04416-1002
US

V. Phone/Fax

Practice location:
  • Phone: 207-469-6589
  • Fax:
Mailing address:
  • Phone: 207-469-6589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT145
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number1241
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: