Basic Information
| Provider Information | |||||||||
| NPI: | 1952418709 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | MAYNARD | ||||||||
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| Credential: | LCPC, CADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 78 ATLANTIC PL | ||||||||
| Address2: | |||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041062316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076616654 | ||||||||
| FaxNumber: | 2078427773 | ||||||||
| Practice Location | |||||||||
| Address1: | 12 WESTBROOK CMN | ||||||||
| Address2: | |||||||||
| City: | WESTBROOK | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040922819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078561500 | ||||||||
| FaxNumber: | 2078561518 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 07/14/2016 | ||||||||
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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 | 101YP2500X | CC2507 | ME | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 101YA0400X | CAC3744 | ME | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 432159799 | 05 | ME | MEDICAID |