Healthcare Provider Details

I. General information

NPI: 1396900585
Provider Name (Legal Business Name): CARLA JANE MOWATT LMSW-CC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2008
Last Update Date: 04/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 HILLCREST AVENUE
RANDOLPH ME
04346
US

IV. Provider business mailing address

33 LINWOOD AVE
AUGUSTA ME
04330-4126
US

V. Phone/Fax

Practice location:
  • Phone: 207-582-9206
  • Fax:
Mailing address:
  • Phone: 207-446-0224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMC11701
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: