Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0200X | Occupational Therapist - Pediatrics | OT1788 | ME |
NPI | 1063518447 |
---|---|
Provider Name | Jessica Lynne Story |
First Address | Lewiston, ME 04240-4542 |
Second Address | Portland, ME 04103-5225 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/09/2006 |
Last Update Date | 09/04/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
418120099 | (05) | ME |