MEDICARE: BETTY L FORTUIN LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LC14392	ME

General Provider Information

NPI Number	:	1144576505
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETTY L FORTUIN LCSW

Provider Business Mailing Address
First Line	:	860 HIGHLAND AVE
Second Line	:
City	:	SOUTH PORTLAND
State	:	ME
Zip	:	04106-6831
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 SHORE RD
Second Line	:	BLDG #326
City	:	CAPE ELIZABETH
State	:	ME
Zip	:	04107-1916
Country	:	US
Telephone Number	:	207-939-5270
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2012
Last Update Date	:	04/09/2014

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