Healthcare Provider Details

I. General information

NPI: 1992011340
Provider Name (Legal Business Name): ANGIE MADORE OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2010
Last Update Date: 10/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

364 PRITHAM AVE
GREENVILLE ME
04441
US

IV. Provider business mailing address

364 PRITHAM AVE
FRENCHTOWN TWP ME
04441-7214
US

V. Phone/Fax

Practice location:
  • Phone: 207-695-5220
  • Fax: 207-695-3709
Mailing address:
  • Phone: 207-695-5257
  • Fax: 204-695-5274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT2030
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: