Healthcare Provider Details

I. General information

NPI: 1679882674
Provider Name (Legal Business Name): BRIAN M. DAVIS MOT OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2010
Last Update Date: 09/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 PINELAND DR SUITE 200
NEW GLOUCESTER ME
04260-5111
US

IV. Provider business mailing address

41 PINELAND DR SUITE 200
NEW GLOUCESTER ME
04260-5111
US

V. Phone/Fax

Practice location:
  • Phone: 207-688-2253
  • Fax: 207-688-4561
Mailing address:
  • Phone: 207-688-2253
  • Fax: 207-688-4561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberTO2428
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: