Healthcare Provider Details

I. General information

NPI: 1134559644
Provider Name (Legal Business Name): BONNIE E. COLLIER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2013
Last Update Date: 06/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 LANCASTER ST
PORTLAND ME
04101-2406
US

IV. Provider business mailing address

78 ATLANTIC PL
SOUTH PORTLAND ME
04106-2316
US

V. Phone/Fax

Practice location:
  • Phone: 207-874-1030
  • Fax: 207-874-1044
Mailing address:
  • Phone: 207-661-6654
  • Fax: 207-842-7773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC15514
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: