MEDICARE: PETER LEE ROSENCRANS PHD

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	390200000X	Student in an Organized Health Care Education/Training Program
2	103TC0700X	Clinical Psychologist	PS2624	ME

General Provider Information

NPI Number	:	1093286577
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETER LEE ROSENCRANS PHD

Provider Business Mailing Address
First Line	:	171 WARREN AVE
Second Line	:
City	:	PORTLAND
State	:	ME
Zip	:	04103-1103
Country	:	US
Telephone Number	:	207-607-4022
Fax Number	:

Provider Business Practice Location Address
First Line	:	171 WARREN AVE
Second Line	:
City	:	PORTLAND
State	:	ME
Zip	:	04103-1103
Country	:	US
Telephone Number	:	207-607-4022
Fax Number	:

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

Provider Enumeration Date	:	12/10/2018
Last Update Date	:	02/05/2025

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