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General NPI Number Information
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NPI Number | 1619136983
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Entity Type | Organization
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Legal Business Name | PSYCHODIAGNOSTIC SERVICES OF SOUTHERN MAINE
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Dates
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Enumeration Date | 06/03/2008
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Last Update Date | 06/03/2008
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Provider Practice Location Address
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Address Line | 491 STEVENS AVE
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City | PORTLAND
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State | ME
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Zip | 04103-2636
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Country | US
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Telephone | 207-828-4026
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Fax |
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Provider Business Mailing Address
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Address Line | 491 STEVENS AVE
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City | PORTLAND
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State | ME
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Zip | 04103-2636
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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 | CHIEF OFFICER
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Name | GREGORY CARBONE
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Credential |
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Telephone | 207-828-4026
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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