Provider Demographics
NPI:1669801882
Name:DELLAIRE, HEIDI
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:DELLAIRE
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 1:40 SCHOOL ST # 2
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-4838
Mailing Address - Country:US
Mailing Address - Phone:207-299-6366
Mailing Address - Fax:
Practice Address - Street 1:17 BRUNSWICK AVE
Practice Address - Street 2:
Practice Address - City:GARDINER
Practice Address - State:ME
Practice Address - Zip Code:04345-2123
Practice Address - Country:US
Practice Address - Phone:207-299-6366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-07
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT4902225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist