Healthcare Provider Details

I. General information

NPI: 1659515120
Provider Name (Legal Business Name): PROJECT PEDS-CHILD DEVELOPMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2009
Last Update Date: 04/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 SILVER STREET
WATERVILLE ME
04901
US

IV. Provider business mailing address

163 SILVER STREET
WATERVILLE ME
04901
US

V. Phone/Fax

Practice location:
  • Phone: 207-877-2498
  • Fax: 207-877-7459
Mailing address:
  • Phone: 207-877-2498
  • Fax: 207-877-7459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: LIZ KEACH
Title or Position: DIRECTOR
Credential:
Phone: 207-877-2498