Healthcare Provider Details

I. General information

NPI: 1083981898
Provider Name (Legal Business Name): CHARISSA ROSE ROBERT LMSW-CC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2011
Last Update Date: 11/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 SAUNDERS WAY SUITE #720
WESTBROOK ME
04092-4833
US

IV. Provider business mailing address

4 MCGILL FERN RD
STANDISH ME
04084-6529
US

V. Phone/Fax

Practice location:
  • Phone: 207-878-9663
  • Fax:
Mailing address:
  • Phone: 207-318-2324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberMC12608
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: