Basic Information
| Provider Information | |||||||||
| NPI: | 1962506675 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EXUBERANT LIVING, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 216 NORTH RD | ||||||||
| Address2: | |||||||||
| City: | DIXMONT | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049323212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079924042 | ||||||||
| FaxNumber: | 2079924043 | ||||||||
| Practice Location | |||||||||
| Address1: | 890 HAMMOND ST | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044014328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079924042 | ||||||||
| FaxNumber: | 2079924043 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | LANE | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2079924042 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | TO1993 | ME | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.