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General NPI Number Information
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NPI Number | 1881851517
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Entity Type | Organization
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Legal Business Name | BAYSIDE NEUROREHABILITATION SERVICES
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Dates
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Enumeration Date | 05/20/2008
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Last Update Date | 05/20/2008
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Provider Practice Location Address
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Address Line | 26 PORTLAND ST
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City | PORTLAND
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State | ME
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Zip | 04101-2912
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Country | US
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Telephone | 207-261-8402
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Fax | 207-271-8405
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Provider Business Mailing Address
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Address Line | 26 PORTLAND ST
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City | PORTLAND
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State | ME
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Zip | 04101-2912
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Country | US
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Telephone | 207-261-8402
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Fax | 207-271-8405
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Authorized Official
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Title or Position | CLINICAL SOCIAL WORKER
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Name | MS. ANN P COSTELLO
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Credential | LCSW
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Telephone | 207-761-8402
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | LC9494
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License Number State | ME
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