Provider Demographics
NPI:1407927411
Name:ANDERSON, DONNA L (OT)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 BAXTER BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-1823
Mailing Address - Country:US
Mailing Address - Phone:207-775-6381
Mailing Address - Fax:207-775-3378
Practice Address - Street 1:43 BAXTER BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-1823
Practice Address - Country:US
Practice Address - Phone:207-775-6381
Practice Address - Fax:207-775-3378
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT1491225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME002415OtherANTHEM BLUE SHIELD
MEMM0108Medicare ID - Type UnspecifiedGROUP PROVIDER ID NUMBER