Healthcare Provider Details

I. General information

NPI: 1841718889
Provider Name (Legal Business Name): DIANA L LAITE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2017
Last Update Date: 07/21/2022
Certification Date: 12/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 MOODY ST
SACO ME
04072-1536
US

IV. Provider business mailing address

50 MOODY ST
SACO ME
04072-1536
US

V. Phone/Fax

Practice location:
  • Phone: 800-434-3000
  • Fax:
Mailing address:
  • Phone: 800-434-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberMC16285
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC17638
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: