Basic Information
Provider Information | |||||||||
NPI: | 1437277878 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARSH | ||||||||
FirstName: | KELLY | ||||||||
MiddleName: | DIANNE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | OTR | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SCANLON | ||||||||
OtherFirstName: | KELLY | ||||||||
OtherMiddleName: | DIANNE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | OTR | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 9 TALL PINES LN | ||||||||
Address2: |   | ||||||||
City: | SACO | ||||||||
State: | ME | ||||||||
PostalCode: | 040729577 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2072836563 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 79 CAT MOUSAM RD | ||||||||
Address2: |   | ||||||||
City: | KENNEBUNK | ||||||||
State: | ME | ||||||||
PostalCode: | 040436924 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2079853030 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/26/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT527 | ME | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
No ID Information.