Provider Demographics
NPI:1710193040
Name:PELLEGRINO, TAMMY ANNE (OT)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:ANNE
Last Name:PELLEGRINO
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:PO BOX 3143
Mailing Address - Street 2:
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-3143
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 CUMBERLAND PL
Practice Address - Street 2:SUITE 108
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5083
Practice Address - Country:US
Practice Address - Phone:207-900-9000
Practice Address - Fax:207-945-8645
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT519225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist