MEDICARE: MS. SUSAN A ANZIVINO 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	101Y00000X	Counselor	CC433	ME

General Provider Information

NPI Number	:	1790774479
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSAN A ANZIVINO PHD

Provider Business Mailing Address
First Line	:	131 FRANKLIN HEALTH CMNS
Second Line	:	STE A
City	:	FARMINGTON
State	:	ME
Zip	:	04938-6142
Country	:	US
Telephone Number	:	207-778-0035
Fax Number	:	207-778-6879

Provider Business Practice Location Address
First Line	:	131 FRANKLIN HEALTH CMNS
Second Line	:	STE A
City	:	FARMINGTON
State	:	ME
Zip	:	04938-6142
Country	:	US
Telephone Number	:	207-778-0035
Fax Number	:	207-778-6879

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

Provider Enumeration Date	:	10/17/2005
Last Update Date	:	07/08/2007

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