Provider Demographics
NPI:1629090519
Name:GAMMON-WILSON, IDA M (LMT, CBT)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:M
Last Name:GAMMON-WILSON
Suffix:
Gender:F
Credentials:LMT, CBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 502
Mailing Address - Street 2:
Mailing Address - City:HALLOWELL
Mailing Address - State:ME
Mailing Address - Zip Code:04347-0502
Mailing Address - Country:US
Mailing Address - Phone:207-622-4062
Mailing Address - Fax:207-622-4062
Practice Address - Street 1:690 MAINE AVE
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:ME
Practice Address - Zip Code:04344-1539
Practice Address - Country:US
Practice Address - Phone:207-622-4062
Practice Address - Fax:207-622-4062
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEME#MT6225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist