Healthcare Provider Details

I. General information

NPI: 1629090519
Provider Name (Legal Business Name): IDA M. GAMMON-WILSON LMT, CBT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 MAINE AVE
FARMINGDALE ME
04344-1539
US

IV. Provider business mailing address

PO BOX 502
HALLOWELL ME
04347-0502
US

V. Phone/Fax

Practice location:
  • Phone: 207-622-4062
  • Fax: 207-622-4062
Mailing address:
  • Phone: 207-622-4062
  • Fax: 207-622-4062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberME#MT6
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: