=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528298882
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRISTA BLONDELL LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2009
-----------------------------------------------------
Last Update Date | 07/21/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 209 WESTERN AVE UNIT G
-----------------------------------------------------
City | SOUTH PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04106-2452
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-272-5638
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 246 BEACH ST
-----------------------------------------------------
City | SACO
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04072-2936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-272-5638
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MT3285
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------