Healthcare Provider Details

I. General information

NPI: 1902412281
Provider Name (Legal Business Name): LUCY MUDFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2020
Last Update Date: 09/25/2020
Certification Date: 09/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 BEACH ST
SACO ME
04072-2812
US

IV. Provider business mailing address

90 BEACH ST
SACO ME
04072-2812
US

V. Phone/Fax

Practice location:
  • Phone: 207-284-4505
  • Fax:
Mailing address:
  • Phone: 207-284-4505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-19-39712
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: