Provider Demographics
NPI:1578029096
Name:NOVAK, KATHERINE
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:NOVAK
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 1:11 CAMPBELL RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1018
Mailing Address - Country:US
Mailing Address - Phone:207-450-4441
Mailing Address - Fax:
Practice Address - Street 1:11 CAMPBELL RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-1018
Practice Address - Country:US
Practice Address - Phone:207-450-4441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT6067225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist