Healthcare Provider Details

I. General information

NPI: 1053391367
Provider Name (Legal Business Name): ANITA LAURETTE GOLLER PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 10/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 CUMBERLAND ST
BRUNSWICK ME
04011-1904
US

IV. Provider business mailing address

6 CUMBERLAND ST
BRUNSWICK ME
04011-1904
US

V. Phone/Fax

Practice location:
  • Phone: 207-729-3092
  • Fax:
Mailing address:
  • Phone: 207-729-3092
  • Fax: 207-729-3092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS904
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: