Healthcare Provider Details

I. General information

NPI: 1508928359
Provider Name (Legal Business Name): KEVIN DAGNESE LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

932 CONGRESS ST
PORTLAND ME
04102-3032
US

IV. Provider business mailing address

932 CONGRESS ST
PORTLAND ME
04102-3032
US

V. Phone/Fax

Practice location:
  • Phone: 207-662-3065
  • Fax: 207-842-7773
Mailing address:
  • Phone: 207-662-3065
  • Fax: 207-842-7773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLS2975
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: