Healthcare Provider Details

I. General information

NPI: 1265911671
Provider Name (Legal Business Name): KATIE R BOVE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATIE R RILEY

II. Dates (important events)

Enumeration Date: 08/08/2018
Last Update Date: 01/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 CENTRAL AVE
LEWISTON ME
04240-6031
US

IV. Provider business mailing address

75 CENTRAL AVE
LEWISTON ME
04240-6031
US

V. Phone/Fax

Practice location:
  • Phone: 207-795-4180
  • Fax: 207-753-6419
Mailing address:
  • Phone: 207-795-4180
  • Fax: 207-753-6419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number120099
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC16055
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: