=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538410972
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHOBHA CHETTY ED.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2012
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 46 FEDERAL ST
-----------------------------------------------------
City | BRUNSWICK
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04011-2125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-319-1900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 GLOVER ST
-----------------------------------------------------
City | BRUNSWICK
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04011-7407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-406-2526
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number | 37-
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------