Healthcare Provider Details

I. General information

NPI: 1538406137
Provider Name (Legal Business Name): JOANNE C BOESCHENSTEIN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2013
Last Update Date: 10/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

778 MAIN ST
SOUTH PORTLAND ME
04106-5447
US

IV. Provider business mailing address

901 WASHINGTON AVE STE 100
PORTLAND ME
04103-2842
US

V. Phone/Fax

Practice location:
  • Phone: 207-879-6160
  • Fax: 207-871-7688
Mailing address:
  • Phone: 207-871-1211
  • Fax: 207-871-1232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberMC13623
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC15362
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: