Healthcare Provider Details

I. General information

NPI: 1255536397
Provider Name (Legal Business Name): JEFFREY MARTIN HAWES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 07/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 WESTMINSTER STREET, SUITE B
LERVISTM ME
04240
US

IV. Provider business mailing address

324 GANNETT DRIVE, SUITE 300
SOUTH PORTLAND ME
04106
US

V. Phone/Fax

Practice location:
  • Phone: 207-786-8122
  • Fax: 207-786-8164
Mailing address:
  • Phone: 207-771-5711
  • Fax: 207-771-5755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberMC 5653
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberMC5653
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: