Provider Demographics
NPI:1457595928
Name:GRONDIN, ANGELA (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:GRONDIN
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-5935
Mailing Address - Country:US
Mailing Address - Phone:207-795-6110
Mailing Address - Fax:207-795-6189
Practice Address - Street 1:618 MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-5935
Practice Address - Country:US
Practice Address - Phone:207-795-6110
Practice Address - Fax:207-795-6189
Is Sole Proprietor?:No
Enumeration Date:2009-04-28
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT2734225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432355099Medicaid