Provider Demographics
NPI:1275747495
Name:MCCANN, KRISTINA GIBSON (MS, OTRL)
Entity Type:Individual
Prefix:MISS
First Name:KRISTINA
Middle Name:GIBSON
Last Name:MCCANN
Suffix:
Gender:F
Credentials:MS, OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 CAT MOUSAM RD
Mailing Address - Street 2:
Mailing Address - City:KENNEBUNK
Mailing Address - State:ME
Mailing Address - Zip Code:04043-6943
Mailing Address - Country:US
Mailing Address - Phone:207-939-0148
Mailing Address - Fax:
Practice Address - Street 1:180 CAT MOUSAM RD
Practice Address - Street 2:
Practice Address - City:KENNEBUNK
Practice Address - State:ME
Practice Address - Zip Code:04043-6943
Practice Address - Country:US
Practice Address - Phone:207-939-0148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT1451225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME206100000Medicaid