Healthcare Provider Details

I. General information

NPI: 1063804953
Provider Name (Legal Business Name): MISS KATIE MARY LISCORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2015
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 COMMERCE DR UNIT 2
AUGUSTA ME
04330-7888
US

IV. Provider business mailing address

16 COMMERCE DR UNIT 2
AUGUSTA ME
04330-7888
US

V. Phone/Fax

Practice location:
  • Phone: 207-233-0401
  • Fax:
Mailing address:
  • Phone: 207-233-0401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: