Healthcare Provider Details

I. General information

NPI: 1043642184
Provider Name (Legal Business Name): ANDREW O'CONNELL-SHEVENELL LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2013
Last Update Date: 07/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 SAINT JOHN ST SUITE 208
PORTLAND ME
04102-3041
US

IV. Provider business mailing address

222 SAINT JOHN ST SUITE 208
PORTLAND ME
04102-3041
US

V. Phone/Fax

Practice location:
  • Phone: 207-358-9631
  • Fax:
Mailing address:
  • Phone: 207-358-9631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT4512
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: