Healthcare Provider Details

I. General information

NPI: 1750610200
Provider Name (Legal Business Name): PHYLLIS JO WARCHOL LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS PHYLLIS JO KANE

II. Dates (important events)

Enumeration Date: 12/11/2009
Last Update Date: 12/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 ALBION RD
WINDHAM ME
04062-4504
US

IV. Provider business mailing address

159 ALBION RD
WINDHAM ME
04062-4504
US

V. Phone/Fax

Practice location:
  • Phone: 207-892-4179
  • Fax:
Mailing address:
  • Phone: 207-892-4179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLC3941
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: