Healthcare Provider Details

I. General information

NPI: 1134699606
Provider Name (Legal Business Name): STEPHANIE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2018
Last Update Date: 11/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 SAINT JOHN ST STE 226
PORTLAND ME
04102-3058
US

IV. Provider business mailing address

28 SMITH ST
SOUTH PORTLAND ME
04106-2238
US

V. Phone/Fax

Practice location:
  • Phone: 207-871-5060
  • Fax:
Mailing address:
  • Phone: 207-871-5060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE ANNE BAIRD
Title or Position: PRESIDENT
Credential: OTR,L.AC.,M.AC
Phone: 207-871-5060