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General NPI Number Information
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NPI Number | 1548675200
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Entity Type | Organization
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Legal Business Name | PORTLAND DOULA COLLABORATIVE
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Dates
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Enumeration Date | 06/21/2014
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Last Update Date | 06/21/2014
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Provider Practice Location Address
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Address Line | 30 UPPER MAST LANDING RD
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City | FREEPORT
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State | ME
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Zip | 04032-6417
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Country | US
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Telephone | 207-632-1242
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Fax |
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Provider Business Mailing Address
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Address Line | 30 UPPER MAST LANDING RD
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City | FREEPORT
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State | ME
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Zip | 04032-6417
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER, LMT, CPMT, DOULA
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Name | MARY E LATENDRESSE
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Credential | LMT, CPMT
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Telephone | 207-632-1242
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 374J00000X
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Taxonomy Name | Doula
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MT2239
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License Number State | ME
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