Provider Demographics
NPI:1043837503
Name:FUNCTIONAL HOME OT LLC
Entity type:Organization
Organization Name:FUNCTIONAL HOME OT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:207-548-5913
Mailing Address - Street 1:255 FIVE RD
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:ME
Mailing Address - Zip Code:04419-3203
Mailing Address - Country:US
Mailing Address - Phone:207-745-4672
Mailing Address - Fax:
Practice Address - Street 1:255 FIVE RD
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:ME
Practice Address - Zip Code:04419-3203
Practice Address - Country:US
Practice Address - Phone:207-548-5913
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-01
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontologyGroup - Single Specialty