Healthcare Provider Details

I. General information

NPI: 1932521085
Provider Name (Legal Business Name): JAIME ELLER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2014
Last Update Date: 04/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

887 CONGRESS ST SUITE 300
PORTLAND ME
04102-3100
US

IV. Provider business mailing address

190 RIVERSIDE ST SUITE 6B
PORTLAND ME
04103-1073
US

V. Phone/Fax

Practice location:
  • Phone: 207-662-5522
  • Fax: 207-662-5527
Mailing address:
  • Phone: 207-661-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC10987
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: