Healthcare Provider Details

I. General information

NPI: 1548675200
Provider Name (Legal Business Name): PORTLAND DOULA COLLABORATIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2014
Last Update Date: 06/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 UPPER MAST LANDING RD
FREEPORT ME
04032-6417
US

IV. Provider business mailing address

30 UPPER MAST LANDING RD
FREEPORT ME
04032-6417
US

V. Phone/Fax

Practice location:
  • Phone: 207-632-1242
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT2239
License Number StateME

VIII. Authorized Official

Name: MARY E LATENDRESSE
Title or Position: OWNER, LMT, CPMT, DOULA
Credential: LMT, CPMT
Phone: 207-632-1242