Healthcare Provider Details

I. General information

NPI: 1508794496
Provider Name (Legal Business Name): EMMANUEL THEODORY DEZDEL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 MOSHER RD
GORHAM ME
04038-5835
US

IV. Provider business mailing address

240 MOSHER RD
GORHAM ME
04038-5835
US

V. Phone/Fax

Practice location:
  • Phone: 207-298-0430
  • Fax: 207-298-0430
Mailing address:
  • Phone: 207-298-0430
  • Fax: 207-298-0430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateME
# 4
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateME
# 5
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateME
# 6
Primary TaxonomyY
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number StateME
# 7
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: