Healthcare Provider Details

I. General information

NPI: 1295820140
Provider Name (Legal Business Name): KRISTEN BOUSE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 05/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

343 FOREST AVE
PORTLAND ME
04101
US

IV. Provider business mailing address

343 FOREST AVE
PORTLAND ME
04101
US

V. Phone/Fax

Practice location:
  • Phone: 207-874-1030
  • Fax: 207-874-1044
Mailing address:
  • Phone: 207-874-1030
  • Fax: 207-874-1044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC10053
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC10053
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: