Healthcare Provider Details

I. General information

NPI: 1700516143
Provider Name (Legal Business Name): ALISE ANSON LMSW-CC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2022
Last Update Date: 06/16/2022
Certification Date: 06/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FODEN RD
SOUTH PORTLAND ME
04106-1717
US

IV. Provider business mailing address

9 LOWELL RD
GORHAM ME
04038-1819
US

V. Phone/Fax

Practice location:
  • Phone: 207-653-5585
  • Fax:
Mailing address:
  • Phone: 845-532-0556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberMC21137
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: