=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982854998
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANA ELAINE KANDILAKIS LCPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2008
-----------------------------------------------------
Last Update Date | 11/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23 JEWETT AVE
-----------------------------------------------------
City | SOUTH BERWICK
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 03908-1109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-312-1820
-----------------------------------------------------
Fax | 207-985-1281
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23 JEWETT AVE
-----------------------------------------------------
City | SOUTH BERWICK
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 03908-1109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-312-1820
-----------------------------------------------------
Fax | 207-985-1281
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | CC1529
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------