Healthcare Provider Details

I. General information

NPI: 1073812665
Provider Name (Legal Business Name): ELISABETH GERALYN HOLDSWORTH PTA, COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2011
Last Update Date: 04/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

895 PORTLAND ROAD
SACO ME
04072
US

IV. Provider business mailing address

895 PORTLAND ROAD
SACO ME
04072
US

V. Phone/Fax

Practice location:
  • Phone: 207-439-5104
  • Fax: 207-571-8134
Mailing address:
  • Phone: 207-439-5104
  • Fax: 207-571-8134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPA3647
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number0A2499
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPA3647
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: