=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982967568
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. ANDREA KELLY SCHACHTNER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2012
-----------------------------------------------------
Last Update Date | 06/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11 BAXTER BLVD
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04101-1801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-775-5671
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1017 CONGRESS ST APT 1
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04102-2717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-819-3620
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | CAC5160
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------