Basic Information
Provider Information | |||||||||
NPI: | 1427183086 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HENCKLER | ||||||||
FirstName: | LAURA | ||||||||
MiddleName: | JANE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MIDDLETON | ||||||||
OtherFirstName: | LAURA | ||||||||
OtherMiddleName: | JANE | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LSW | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 78 ATLANTIC PLACE | ||||||||
Address2: |   | ||||||||
City: | SOUTH PORTLAND | ||||||||
State: | ME | ||||||||
PostalCode: | 041062316 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2078427701 | ||||||||
FaxNumber: | 2078427773 | ||||||||
Practice Location | |||||||||
Address1: | 453 US ROUTE 1 | ||||||||
Address2: |   | ||||||||
City: | KITTERY | ||||||||
State: | ME | ||||||||
PostalCode: | 039045513 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2074511750 | ||||||||
FaxNumber: | 2074394360 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/23/2007 | ||||||||
LastUpdateDate: | 06/18/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LC14040 | ME | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.