Healthcare Provider Details

I. General information

NPI: 1629337910
Provider Name (Legal Business Name): KAREN DEYESSO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2012
Last Update Date: 05/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 OCEAN AVE
PORTLAND ME
04103-4973
US

IV. Provider business mailing address

535 OCEAN AVE
PORTLAND ME
04103-4973
US

V. Phone/Fax

Practice location:
  • Phone: 207-232-6088
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT1867
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: