Healthcare Provider Details

I. General information

NPI: 1477969541
Provider Name (Legal Business Name): GRETCHEN JEFFERSON PH.D., BCBA-D, NCSP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2014
Last Update Date: 07/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 SAUNDERS WAY WOODFORDS FAMILY SERVICES
WESTBROOK ME
04092
US

IV. Provider business mailing address

1 CRESCENT ST # 1
PORTLAND ME
04102-3114
US

V. Phone/Fax

Practice location:
  • Phone: 207-232-7443
  • Fax:
Mailing address:
  • Phone: 207-232-7443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-04-1922
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number31656
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: