=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255814232
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HALEY SMITH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2018
-----------------------------------------------------
Last Update Date | 09/14/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 758 BROADWAY
-----------------------------------------------------
City | BANGOR
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-941-8400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 199 BOMARC RD APT 21
-----------------------------------------------------
City | BANGOR
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04401-2696
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-554-9424
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT5135
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------