Healthcare Provider Details

I. General information

NPI: 1245955988
Provider Name (Legal Business Name): CHLOE GUSTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2022
Last Update Date: 10/05/2022
Certification Date: 10/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 CAPITOL ST STE 4
AUGUSTA ME
04330-6262
US

IV. Provider business mailing address

151 CAPITOL ST STE 4
AUGUSTA ME
04330-6262
US

V. Phone/Fax

Practice location:
  • Phone: 207-512-8549
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License NumberRN79440
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: