Healthcare Provider Details

I. General information

NPI: 1467888024
Provider Name (Legal Business Name): SAVANNAH C. KIRCHNER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAVANNAH C COOKSON

II. Dates (important events)

Enumeration Date: 09/16/2013
Last Update Date: 01/04/2021
Certification Date: 12/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CAMPUS AVE STE A&B
LEWISTON ME
04240-6040
US

IV. Provider business mailing address

C/O ST MARYS HEALTH SYSTEM - PROVIDER ENROLLMENT PO BOX 7291
LEWISTON ME
04243-7291
US

V. Phone/Fax

Practice location:
  • Phone: 207-755-3434
  • Fax: 207-755-3474
Mailing address:
  • Phone: 207-777-8950
  • Fax: 207-777-8800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC15458
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: