Provider Demographics
NPI:1043708621
Name:CASTONGUAY, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CASTONGUAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 DEERING RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:EAST WATERBORO
Mailing Address - State:ME
Mailing Address - Zip Code:04030-5312
Mailing Address - Country:US
Mailing Address - Phone:207-459-0927
Mailing Address - Fax:
Practice Address - Street 1:163 DEERING RIDGE RD
Practice Address - Street 2:
Practice Address - City:EAST WATERBORO
Practice Address - State:ME
Practice Address - Zip Code:04030-5312
Practice Address - Country:US
Practice Address - Phone:207-459-0927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-28
Last Update Date:2018-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT609225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist