Healthcare Provider Details

I. General information

NPI: 1710221890
Provider Name (Legal Business Name): KRISTINA MARIE LAUDERBACK MSS, MLSP, L.C.S.W
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 MAIN ST
PORTER ME
04068-3527
US

IV. Provider business mailing address

70 MAIN ST
PORTER ME
04068-3527
US

V. Phone/Fax

Practice location:
  • Phone: 207-625-8126
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC18460
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: