Healthcare Provider Details

I. General information

NPI: 1497265219
Provider Name (Legal Business Name): GRACE ELISABETH BEDARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2017
Last Update Date: 10/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 FORE ST FL 2
PORTLAND ME
04101-4879
US

IV. Provider business mailing address

131 COOPER HILL RD
NOTTINGHAM NH
03290-6015
US

V. Phone/Fax

Practice location:
  • Phone: 207-773-5778
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10514
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT4644
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: