=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831252048
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BETH M WOODBREY-JOHNSON OTR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2006
-----------------------------------------------------
Last Update Date | 01/28/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 281 BURLEIGH RD
-----------------------------------------------------
City | BANGOR
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04401-2511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-262-7173
-----------------------------------------------------
Fax | 207-947-2465
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 835
-----------------------------------------------------
City | BANGOR
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04402-0835
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-262-7173
-----------------------------------------------------
Fax | 207-947-2465
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT219
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------