Healthcare Provider Details

I. General information

NPI: 1407680549
Provider Name (Legal Business Name): ALISHA LYNNETTE IDDINGS CAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2024
Last Update Date: 08/30/2024
Certification Date: 08/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87 S HIGH ST
BRIDGTON ME
04009-1123
US

IV. Provider business mailing address

87 S HIGH ST
BRIDGTON ME
04009-1123
US

V. Phone/Fax

Practice location:
  • Phone: 207-647-5600
  • Fax:
Mailing address:
  • Phone: 207-647-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: