Provider Demographics
NPI:1134664832
Name:LAFOREST, MARISA (OT)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:LAFOREST
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:
Other - Last Name:CRUDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:190 RIVERSIDE ST
Mailing Address - Street 2:SUITE 6B
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1073
Mailing Address - Country:US
Mailing Address - Phone:207-661-2000
Mailing Address - Fax:
Practice Address - Street 1:55 SPRING STREET
Practice Address - Street 2:SUITE A
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074
Practice Address - Country:US
Practice Address - Phone:207-396-7337
Practice Address - Fax:207-885-4349
Is Sole Proprietor?:No
Enumeration Date:2017-01-04
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT1437225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEE400359616Medicare PIN