Healthcare Provider Details

I. General information

NPI: 1790400877
Provider Name (Legal Business Name): MS. ANA BROOK COURTNEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2022
Last Update Date: 10/11/2022
Certification Date: 10/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

741 WARREN AVENUE
PORTLAND ME
04103
US

IV. Provider business mailing address

165 LEXINGTON AVENUE
PORTLAND ME
04103
US

V. Phone/Fax

Practice location:
  • Phone: 207-879-6165
  • Fax: 207-879-7466
Mailing address:
  • Phone: 207-712-7427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMC20967
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: