Healthcare Provider Details

I. General information

NPI: 1730225921
Provider Name (Legal Business Name): ANDREA KJENSTAD SA COUNSELOR - LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 MILL ST
HOULTON ME
04730-1877
US

IV. Provider business mailing address

11 MILL ST
HOULTON ME
04730-1877
US

V. Phone/Fax

Practice location:
  • Phone: 207-532-6523
  • Fax: 207-532-3873
Mailing address:
  • Phone: 207-532-6523
  • Fax: 207-532-3873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLC3321
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: