=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154639540
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PORTLAND PUBLIC SCHOOLS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2010
-----------------------------------------------------
Last Update Date | 09/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 196 ALLEN AVE
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04103-3711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-874-8133
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 196 ALLEN AVE
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04103-3711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-874-8133
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | PATRICIA DYER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 207-874-8133
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251300000X
-----------------------------------------------------
Taxonomy Name | Local Education Agency (LEA)
-----------------------------------------------------
License Number | PT228
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------