Healthcare Provider Details

I. General information

NPI: 1760637342
Provider Name (Legal Business Name): BONNY LEE SAXON BA, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2008
Last Update Date: 11/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 WATER ST
RANDOLPH ME
04346-5101
US

IV. Provider business mailing address

129 WATER ST
RANDOLPH ME
04346-5101
US

V. Phone/Fax

Practice location:
  • Phone: 207-582-8158
  • Fax:
Mailing address:
  • Phone: 207-582-8158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number417
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: