Healthcare Provider Details

I. General information

NPI: 1881851517
Provider Name (Legal Business Name): BAYSIDE NEUROREHABILITATION SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2008
Last Update Date: 05/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 PORTLAND ST
PORTLAND ME
04101-2912
US

IV. Provider business mailing address

26 PORTLAND ST
PORTLAND ME
04101-2912
US

V. Phone/Fax

Practice location:
  • Phone: 207-261-8402
  • Fax: 207-271-8405
Mailing address:
  • Phone: 207-261-8402
  • Fax: 207-271-8405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberLC9494
License Number StateME

VIII. Authorized Official

Name: MS. ANN P COSTELLO
Title or Position: CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 207-761-8402