Healthcare Provider Details

I. General information

NPI: 1124787189
Provider Name (Legal Business Name): MAURA E PITLUCK OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2021
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 SHAPE DR
KENNEBUNK ME
04043-6760
US

IV. Provider business mailing address

4 SHAPE DR
KENNEBUNK ME
04043-6760
US

V. Phone/Fax

Practice location:
  • Phone: 207-662-5143
  • Fax: 207-661-8104
Mailing address:
  • Phone: 207-662-5143
  • Fax: 207-661-8104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT4608
License Number StateME

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: