Healthcare Provider Details

I. General information

NPI: 1912949108
Provider Name (Legal Business Name): SARAH E DALY ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 FODEN RD SUITE 103W
SOUTH PORTLAND ME
04106-2319
US

IV. Provider business mailing address

100 FODEN RD SUITE 103W
SOUTH PORTLAND ME
04106-2319
US

V. Phone/Fax

Practice location:
  • Phone: 207-772-2625
  • Fax: 207-879-4246
Mailing address:
  • Phone: 207-772-2625
  • Fax: 207-879-4246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT284
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: