Healthcare Provider Details

I. General information

NPI: 1134591712
Provider Name (Legal Business Name): DUSTIN BLACKINGTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2015
Last Update Date: 11/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

244 WESTERN AVENUE
SOUTH PORTLAND ME
04106
US

IV. Provider business mailing address

244 WESTERN AVENUE
SOUTH PORTLAND ME
04106
US

V. Phone/Fax

Practice location:
  • Phone: 207-775-3446
  • Fax: 207-879-1646
Mailing address:
  • Phone: 207-775-3446
  • Fax: 207-879-1646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number117258
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT3637
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: