Healthcare Provider Details

I. General information

NPI: 1245314400
Provider Name (Legal Business Name): JILL E WATROUS L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 SPURWINK DROVE
CHELSEA ME
04330
US

IV. Provider business mailing address

899 RIVERSIDE ST
PORTLAND ME
04103-1070
US

V. Phone/Fax

Practice location:
  • Phone: 207-582-7686
  • Fax: 207-582-7688
Mailing address:
  • Phone: 207-871-1200
  • Fax: 207-871-1232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOA1921
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: