Basic Information
| Provider Information | |||||||||
| NPI: | 1265448336 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SWENSON | ||||||||
| FirstName: | LORRAINE | ||||||||
| MiddleName: | KIMBALL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KIMBALL | ||||||||
| OtherFirstName: | LORRAINE | ||||||||
| OtherMiddleName: | DEL | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCPC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 78 ATLANTIC PL | ||||||||
| Address2: | |||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041062316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078427701 | ||||||||
| FaxNumber: | 2078427773 | ||||||||
| Practice Location | |||||||||
| Address1: | 474 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGVALE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040831409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073241500 | ||||||||
| FaxNumber: | 2074905263 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 11/05/2012 | ||||||||
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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 | 101YM0800X | CC3336 | ME | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | CC3336 | ME | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 432108099 | 05 | ME | MEDICAID |