Healthcare Provider Details

I. General information

NPI: 1316130511
Provider Name (Legal Business Name): KAREN AMANDA DEGRANDPRE LMSW-CC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2007
Last Update Date: 08/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CAMPUS DR UNIT 107
SCARBOROUGH ME
04074-9692
US

IV. Provider business mailing address

39 WALLACE AVE
SOUTH PORTLAND ME
04106-6143
US

V. Phone/Fax

Practice location:
  • Phone: 207-885-7565
  • Fax: 207-885-7577
Mailing address:
  • Phone: 207-761-0650
  • Fax: 207-761-8198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberMC11270
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: