Provider Demographics
NPI:1568955540
Name:COMEAU, AUDREY ROSE
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:ROSE
Last Name:COMEAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 FESSENDEN ST APT 2
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-4818
Mailing Address - Country:US
Mailing Address - Phone:603-325-2109
Mailing Address - Fax:
Practice Address - Street 1:5 DUNAWAY DR
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:ME
Practice Address - Zip Code:04073-5143
Practice Address - Country:US
Practice Address - Phone:207-324-7955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
METO3501225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics