Healthcare Provider Details

I. General information

NPI: 1265419675
Provider Name (Legal Business Name): ANN M ALTAVILLA O.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 06/30/2024
Certification Date: 06/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 EQUESTRIAN WAY
SCARBOROUGH ME
04074-9628
US

IV. Provider business mailing address

9 EQUESTRIAN WAY
SCARBOROUGH ME
04074-9628
US

V. Phone/Fax

Practice location:
  • Phone: 207-229-8732
  • Fax:
Mailing address:
  • Phone: 207-229-8732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT1663
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: