Provider Demographics
NPI:1740880822
Name:INTEGRATIVE SOMATIC TRAUMA THERAPY
Entity type:Organization
Organization Name:INTEGRATIVE SOMATIC TRAUMA THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:GALE
Authorized Official - Middle Name:
Authorized Official - Last Name:KURTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-815-0371
Mailing Address - Street 1:45 GRAND ST APT 4
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2268
Mailing Address - Country:US
Mailing Address - Phone:207-815-0371
Mailing Address - Fax:
Practice Address - Street 1:45 GRAND ST APT 4
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2268
Practice Address - Country:US
Practice Address - Phone:207-815-0371
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service