Healthcare Provider Details

I. General information

NPI: 1013271188
Provider Name (Legal Business Name): MEAGEN A MAYO LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2012
Last Update Date: 07/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 SPURWINK DR
CHELSEA ME
04330-1166
US

IV. Provider business mailing address

899 RIVERSIDE ST
PORTLAND ME
04103-1070
US

V. Phone/Fax

Practice location:
  • Phone: 207-582-7686
  • Fax: 207-582-7688
Mailing address:
  • Phone: 207-871-1211
  • Fax: 207-871-1232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLS13457
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: