Healthcare Provider Details

I. General information

NPI: 1548356900
Provider Name (Legal Business Name): SUSAN LIDSTONE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 09/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 UNION ST
ROCKLAND ME
04841-2739
US

IV. Provider business mailing address

78 ATLANTIC PL
SOUTH PORTLAND ME
04106-2316
US

V. Phone/Fax

Practice location:
  • Phone: 207-701-4400
  • Fax: 207-701-4486
Mailing address:
  • Phone: 207-842-6556
  • Fax: 207-842-7773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN20742
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP81772
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License NumberCNS84119
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: