Basic Information
Provider Information
NPI: 1003142134
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BUBIER
FirstName: JACALYN
MiddleName: DAWN
NamePrefix:  
NameSuffix:  
Credential: OTR/L
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 10 MAY ST
Address2:  
City: BIDDEFORD
State: ME
PostalCode: 040052923
CountryCode: US
TelephoneNumber: 2072824138
FaxNumber: 2072828242
Practice Location
Address1: 10 MAY ST
Address2:  
City: BIDDEFORD
State: ME
PostalCode: 040052923
CountryCode: US
TelephoneNumber: 2072824138
FaxNumber: 2072828242
Other Information
ProviderEnumerationDate: 10/24/2009
LastUpdateDate: 10/24/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225X00000X939MEY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist 

No ID Information.


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