MEDICARE: MARIA A MOUSTROUPHIS LCSW, LADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	ME317297	ME
2	1041C0700X	Clinical Social Worker	ME324956	ME

General Provider Information

NPI Number	:	1003037912
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIA A MOUSTROUPHIS LCSW, LADC

Provider Business Mailing Address
First Line	:	77 VERMONT AVE
Second Line	:
City	:	PORTLAND
State	:	ME
Zip	:	04103-3922
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	77 VERMONT AVE
Second Line	:
City	:	PORTLAND
State	:	ME
Zip	:	04103-3922
Country	:	US
Telephone Number	:	207-409-9487
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	11/05/2021

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