Provider Demographics
NPI:1831252048
Name:WOODBREY-JOHNSON, BETH M (OTR)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:M
Last Name:WOODBREY-JOHNSON
Suffix:
Gender:F
Credentials:OTR
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 835
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-0835
Mailing Address - Country:US
Mailing Address - Phone:207-262-7173
Mailing Address - Fax:207-947-2465
Practice Address - Street 1:281 BURLEIGH RD
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-2511
Practice Address - Country:US
Practice Address - Phone:207-262-7173
Practice Address - Fax:207-947-2465
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT219225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME202200099Medicaid
ME202200099Medicaid