Provider Demographics
NPI:1881851517
Name:BAYSIDE NEUROREHABILITATION SERVICES
Entity type:Organization
Organization Name:BAYSIDE NEUROREHABILITATION SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANN
Authorized Official - Middle Name:P
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:207-761-8402
Mailing Address - Street 1:26 PORTLAND ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2912
Mailing Address - Country:US
Mailing Address - Phone:207-261-8402
Mailing Address - Fax:207-271-8405
Practice Address - Street 1:26 PORTLAND ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2912
Practice Address - Country:US
Practice Address - Phone:207-261-8402
Practice Address - Fax:207-271-8405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC9494261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty