Healthcare Provider Details

I. General information

NPI: 1154620482
Provider Name (Legal Business Name): SUSAN M SOVEREL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2011
Last Update Date: 10/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

469 MAIN ST STE 206
SPRINGVALE ME
04083-1871
US

IV. Provider business mailing address

469 MAIN ST STE 206
SPRINGVALE ME
04083-1871
US

V. Phone/Fax

Practice location:
  • Phone: 207-490-5389
  • Fax: 207-490-5390
Mailing address:
  • Phone: 207-490-5389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC5939
License Number StateME

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: