Healthcare Provider Details

I. General information

NPI: 1134370570
Provider Name (Legal Business Name): MARIANNE C. BERUBE COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2008
Last Update Date: 10/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 PORTLAND RD
KENNEBUNK ME
04043-6656
US

IV. Provider business mailing address

58 PORTLAND RD P.O. BOX 1084
KENNEBUNK ME
04043-6656
US

V. Phone/Fax

Practice location:
  • Phone: 207-432-2296
  • Fax: 207-799-9353
Mailing address:
  • Phone: 207-432-2296
  • Fax: 207-799-9353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberLC11467
License Number StateME

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MARIANNE C. BERUBE
Title or Position: COUNSELOR
Credential: LCSW
Phone: 207-432-2296