Provider Demographics
NPI:1043642184
Name:O'CONNELL-SHEVENELL, ANDREW (LMT)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:O'CONNELL-SHEVENELL
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 SAINT JOHN ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3041
Mailing Address - Country:US
Mailing Address - Phone:207-358-9631
Mailing Address - Fax:
Practice Address - Street 1:222 SAINT JOHN ST
Practice Address - Street 2:SUITE 208
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3041
Practice Address - Country:US
Practice Address - Phone:207-358-9631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT4512225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist