Healthcare Provider Details

I. General information

NPI: 1386762219
Provider Name (Legal Business Name): KAREN SCUTT POTENZIANO MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 ALLEN AVE CASCO BAY HIGH SCHOOL
PORTLAND ME
04103-3711
US

IV. Provider business mailing address

480 ROYAL RD
NORTH YARMOUTH ME
04097-6911
US

V. Phone/Fax

Practice location:
  • Phone: 207-939-4369
  • Fax:
Mailing address:
  • Phone: 207-939-4369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC6116
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: