Healthcare Provider Details

I. General information

NPI: 1770766156
Provider Name (Legal Business Name): LESLIE A. GOULET OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2007
Last Update Date: 12/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

647 US ROUTE 1 306
YORK ME
03909-1651
US

IV. Provider business mailing address

647 US ROUTE 1 306
YORK ME
03909-1651
US

V. Phone/Fax

Practice location:
  • Phone: 207-363-3974
  • Fax:
Mailing address:
  • Phone: 207-363-3974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License NumberOT 60
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: