Basic Information
| Provider Information | |||||||||
| NPI: | 1235466442 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARDONA | ||||||||
| FirstName: | PAULA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 525 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041065462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078741045 | ||||||||
| FaxNumber: | 2077670995 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041065462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078741045 | ||||||||
| FaxNumber: | 2077670995 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2009 | ||||||||
| LastUpdateDate: | 11/09/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 101Y00000X | ME | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 252680099 | 05 | ME | MEDICAID |