Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PT3825 | ME |
NPI | 1003195140 |
---|---|
Provider Name | Kelsey Bushover |
First Address | Vassalboro, ME 04989-3743 |
Second Address | Vassalboro, ME 04989-3743 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/08/2011 |
Last Update Date | 08/08/2011 |