Healthcare Provider Details

I. General information

NPI: 1619685138
Provider Name (Legal Business Name): SHORELINE COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2022
Last Update Date: 12/20/2022
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 MAIN ST STE 4
WESTBROOK ME
04092-2873
US

IV. Provider business mailing address

825 MAIN ST STE 4
WESTBROOK ME
04092-2873
US

V. Phone/Fax

Practice location:
  • Phone: 207-228-3880
  • Fax: 207-805-8853
Mailing address:
  • Phone: 207-228-3880
  • Fax: 207-805-8853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: KEARA ANNE DUPONT ANCTIL
Title or Position: OWNER
Credential: LCSW
Phone: 208-228-3880