Healthcare Provider Details

I. General information

NPI: 1245361468
Provider Name (Legal Business Name): ELISE C MAGNUSON PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 09/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 WOODFORD ST
PORTLAND ME
04103-5617
US

IV. Provider business mailing address

251 WOODFORD ST
PORTLAND ME
04103-5617
US

V. Phone/Fax

Practice location:
  • Phone: 207-632-6965
  • Fax: 207-761-8150
Mailing address:
  • Phone: 207-632-6965
  • Fax: 207-761-8150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS 1242
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC11425
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: