Healthcare Provider Details

I. General information

NPI: 1427776210
Provider Name (Legal Business Name): KAYLA BLACKBOROW LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2022
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

576 SAINT JOHN ST
PORTLAND ME
04102-2710
US

IV. Provider business mailing address

576 SAINT JOHN ST
PORTLAND ME
04102-2710
US

V. Phone/Fax

Practice location:
  • Phone: 207-661-0700
  • Fax: 207-536-6720
Mailing address:
  • Phone: 207-661-0700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number228110
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC23814
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLC8564
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: