Healthcare Provider Details

I. General information

NPI: 1073968905
Provider Name (Legal Business Name): LISA MARIE MACDONALD MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LISA MARIE CROWLEY MSW

II. Dates (important events)

Enumeration Date: 04/28/2016
Last Update Date: 10/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 CAMPBELL CIR
KENNEBUNK ME
04043-6838
US

IV. Provider business mailing address

4 CAMPBELL CIR
KENNEBUNK ME
04043-6838
US

V. Phone/Fax

Practice location:
  • Phone: 207-985-9939
  • Fax:
Mailing address:
  • Phone: 207-985-9939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW110393-1
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC8956
License Number StateME

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: