Healthcare Provider Details

I. General information

NPI: 1275570400
Provider Name (Legal Business Name): JENNIFER M TINGLEY PRINCE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 08/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 ELM ST
PORTLAND ME
04101-3091
US

IV. Provider business mailing address

29 FRANKLIN ST
BANGOR ME
04401-4909
US

V. Phone/Fax

Practice location:
  • Phone: 207-553-7056
  • Fax: 207-773-2082
Mailing address:
  • Phone: 207-942-3816
  • Fax: 207-561-4725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLC10171
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: