Basic Information
| Provider Information | |||||||||
| NPI: | 1912554130 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GADDAR | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW-CC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAISS | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 50 MOODY ST | ||||||||
| Address2: | |||||||||
| City: | SACO | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040721536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004343000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 50 MOODY ST | ||||||||
| Address2: | |||||||||
| City: | SACO | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040721536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004343000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2019 | ||||||||
| LastUpdateDate: | 08/22/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | MC18188 | ME | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.