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General NPI Number Information
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NPI Number | 1134439151
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Entity Type | Organization
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Legal Business Name | MAST CLINIC, INC
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Dates
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Enumeration Date | 10/08/2010
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Last Update Date | 10/08/2010
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Provider Practice Location Address
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Address Line | 1 WESTBROOK CMN SUITE 2
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City | WESTBROOK
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State | ME
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Zip | 04092-2804
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Country | US
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Telephone | 207-892-5328
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Fax | 866-416-3820
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Provider Business Mailing Address
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Address Line | 94 RACKLEFF ST
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City | PORTLAND
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State | ME
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Zip | 04103-3054
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Country | US
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Telephone | 207-892-5328
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Fax |
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Authorized Official
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Title or Position | OWNER/MANAGER/PROVIDER
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Name | MS. JACQUELINE D MAST
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Credential | PT MSED
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Telephone | 207-892-5328
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number | PT677
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License Number State | ME
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