Healthcare Provider Details

I. General information

NPI: 1154911238
Provider Name (Legal Business Name): CASEY WYMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2021
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145 BRIGHTON AVE
PORTLAND ME
04102-1075
US

IV. Provider business mailing address

108 OAKLAND AVE
WESTBROOK ME
04092-4026
US

V. Phone/Fax

Practice location:
  • Phone: 207-541-6500
  • Fax:
Mailing address:
  • Phone: 207-479-1963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOA3740
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: