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General NPI Number Information
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NPI Number | 1245974708
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Entity Type | Individual
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Provider Name | MICHELLE FORBES SUMMERVILLE
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Gender | Female
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Dates
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Enumeration Date | 04/21/2022
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Last Update Date | 04/21/2022
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Provider Practice Location Address
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Address Line | COASTAL KIDS OT 1222 PORTLAND RD
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City | ARUNDEL
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State | ME
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Zip | 04046
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Country | US
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Telephone | 207-337-1058
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Fax |
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Provider Business Mailing Address
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Address Line | 77 ROBERTS POND RD
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City | LYMAN
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State | ME
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Zip | 04002-6714
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Country | US
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Telephone | 207-544-3925
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080P0008X
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Taxonomy Name | Pediatric Neurodevelopmental Disabilities Physician
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License Number | PA4434
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License Number State | ME
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