Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225X00000X | Occupational Therapist | ||
Y | 225XM0800X | Mental Health |
NPI | 1215401344 |
---|---|
Provider Name | Nicole Madore |
First Address | Bangor, ME 04401-3980 |
Second Address | Bangor, ME 04401-3980 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/01/2019 |
Last Update Date | 11/01/2019 |