Healthcare Provider Details

I. General information

NPI: 1417922725
Provider Name (Legal Business Name): LARISSA ARAXE MEAD-WESCOTT PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LARISSA ARAXE MEAD

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 11/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

277 STATE ST SUITE 2A
BANGOR ME
04401-5439
US

IV. Provider business mailing address

277 STATE ST SUITE 2A
BANGOR ME
04401-5439
US

V. Phone/Fax

Practice location:
  • Phone: 207-990-2580
  • Fax: 207-990-1930
Mailing address:
  • Phone: 207-990-2580
  • Fax: 207-990-1930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPS960
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: