Healthcare Provider Details

I. General information

NPI: 1477800159
Provider Name (Legal Business Name): BETH ELLEN FAWCETT LMSW-CC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2012
Last Update Date: 08/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 PARK RD SUITE 4
WESTBROOK ME
04092-3176
US

IV. Provider business mailing address

899 RIVERSIDE ST
PORTLAND ME
04103-1070
US

V. Phone/Fax

Practice location:
  • Phone: 207-856-0082
  • Fax: 207-856-2861
Mailing address:
  • Phone: 207-871-1211
  • Fax: 207-871-1232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberMC13653
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: