=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740405554
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH SUE BLANCHETTE LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2007
-----------------------------------------------------
Last Update Date | 09/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 324 GANNETT DRIVE SUITE 300
-----------------------------------------------------
City | SOUTH PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-771-5700
-----------------------------------------------------
Fax | 207-771-5750
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 787
-----------------------------------------------------
City | ELLSWORTH
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04605-0787
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-667-0909
-----------------------------------------------------
Fax | 207-667-6348
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | LC6734
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------