=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548748171
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARAH GLEESON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2018
-----------------------------------------------------
Last Update Date | 08/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 NORTH ST STE 2
-----------------------------------------------------
City | SACO
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-282-7121
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 SOUTHWELL RD
-----------------------------------------------------
City | CAPE ELIZABETH
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04107-1219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | PT5142
-----------------------------------------------------
License Number State |
-----------------------------------------------------