Healthcare Provider Details

I. General information

NPI: 1043837503
Provider Name (Legal Business Name): FUNCTIONAL HOME OT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2020
Last Update Date: 06/05/2023
Certification Date: 06/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 FIVE RD
CARMEL ME
04419-3203
US

IV. Provider business mailing address

255 FIVE RD
CARMEL ME
04419-3203
US

V. Phone/Fax

Practice location:
  • Phone: 207-548-5913
  • Fax:
Mailing address:
  • Phone: 207-745-4672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MELISSA ANNE LOPEZ
Title or Position: OWNER
Credential: OTR/L
Phone: 207-548-5913