Healthcare Provider Details

I. General information

NPI: 1932607801
Provider Name (Legal Business Name): PORTLAND INSTITUTE FOR PSYCHOTHERAPY AND TRAINING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2018
Last Update Date: 07/18/2024
Certification Date: 07/18/2024
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 NumberLC10604
License Number StateME

VIII. Authorized Official

Name: LINDY GRAHAM
Title or Position: OWNER/PSYCHOTHERAPIST
Credential: LCSW
Phone: 207-619-3356