Provider Demographics
NPI:1053436592
Name:PINE, SHELLEY J (OT)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:J
Last Name:PINE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 GANNETT DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3266
Mailing Address - Country:US
Mailing Address - Phone:207-482-7800
Mailing Address - Fax:207-482-7898
Practice Address - Street 1:33 SEWALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2603
Practice Address - Country:US
Practice Address - Phone:207-828-2121
Practice Address - Fax:207-553-7166
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO970184225X00000X
MEOT4487225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist