Basic Information
Provider Information | |||||||||
NPI: | 1144235581 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOBBI | ||||||||
FirstName: | BEVERLY | ||||||||
MiddleName: | J. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 78 ATLANTIC PL | ||||||||
Address2: |   | ||||||||
City: | SOUTH PORTLAND | ||||||||
State: | ME | ||||||||
PostalCode: | 041062316 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2076616654 | ||||||||
FaxNumber: | 2078427773 | ||||||||
Practice Location | |||||||||
Address1: | 2 SPRINGBROOK DR | ||||||||
Address2: |   | ||||||||
City: | BIDDEFORD | ||||||||
State: | ME | ||||||||
PostalCode: | 040059443 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2072821500 | ||||||||
FaxNumber: | 2072822581 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/31/2006 | ||||||||
LastUpdateDate: | 06/22/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | RN49398 | ME | N |   | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 163W00000X | 036763-21 | NH | Y |   | Nursing Service Providers | Registered Nurse |   |
ID Information
ID | Type | State | Issuer | Description | 271220099 | 05 | ME |   | MEDICAID |