Healthcare Provider Details

I. General information

NPI: 1700545712
Provider Name (Legal Business Name): FAYE E DIBELLA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2021
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 DANFORTH ST STE 311
PORTLAND ME
04101-4574
US

IV. Provider business mailing address

PO BOX 8484
PORTLAND ME
04104-8484
US

V. Phone/Fax

Practice location:
  • Phone: 207-619-3356
  • Fax: 207-300-6085
Mailing address:
  • Phone: 207-619-3356
  • Fax: 207-300-6085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC23235
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: