Basic Information
Provider Information | |||||||||
NPI: | 1437197001 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PODRAZA | ||||||||
FirstName: | ANTHONY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PH.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 43 WHITING HILL RD | ||||||||
Address2: | SUITE 300 | ||||||||
City: | BREWER | ||||||||
State: | ME | ||||||||
PostalCode: | 044121005 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2079735035 | ||||||||
FaxNumber: | 2079735042 | ||||||||
Practice Location | |||||||||
Address1: | 905 UNION ST | ||||||||
Address2: | SUITE 9 | ||||||||
City: | BANGOR | ||||||||
State: | ME | ||||||||
PostalCode: | 044013050 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2079734037 | ||||||||
FaxNumber: | 2079738276 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/03/2006 | ||||||||
LastUpdateDate: | 03/18/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | PS637 | ME | Y |   | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |   |
No ID Information.