Healthcare Provider Details

I. General information

NPI: 1740352541
Provider Name (Legal Business Name): ROBERTA LEE ZUCKERMAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 PROSPECT ST
PORTLAND ME
04103-4018
US

IV. Provider business mailing address

46 PROSPECT ST
PORTLAND ME
04103-4018
US

V. Phone/Fax

Practice location:
  • Phone: 207-761-9709
  • Fax:
Mailing address:
  • Phone: 207-761-9709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberLC4516
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: