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General NPI Number Information
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NPI Number | 1104053867
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Entity Type | Organization
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Legal Business Name | CENTER FOR SACRED LIVING
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Dates
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Enumeration Date | 06/19/2009
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Last Update Date | 06/19/2009
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Provider Practice Location Address
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Address Line | 69 ANGELL AVE APT 1
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City | SOUTH PORTLAND
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State | ME
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Zip | 04106-5002
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Country | US
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Telephone | 207-221-0727
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Fax |
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Provider Business Mailing Address
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Address Line | 69 ANGELL AVE APT 1
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City | SOUTH PORTLAND
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State | ME
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Zip | 04106-5002
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Country | US
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Telephone | 207-221-0727
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Fax |
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Authorized Official
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Title or Position | DIRECTOR OF CLINICAL SERVICES
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Name | MRS. DEBRA GRETEN-GANBERG
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Credential | LCSW
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Telephone | 207-221-0727
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | AC1
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License Number State | ME
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | LC6487
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License Number State | ME
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