Basic Information
Provider Information | |||||||||
NPI: | 1023259892 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SPITKO | ||||||||
FirstName: | REBECCA | ||||||||
MiddleName: | W | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LS11320 | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 899 RIVERSIDE ST | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | ME | ||||||||
PostalCode: | 041031070 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2078711200 | ||||||||
FaxNumber: | 2078711232 | ||||||||
Practice Location | |||||||||
Address1: | 17 BISHOP ST | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | ME | ||||||||
PostalCode: | 041032659 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2078711235 | ||||||||
FaxNumber: | 2078796161 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/09/2009 | ||||||||
LastUpdateDate: | 03/09/2009 | ||||||||
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 | 171M00000X | LS11320 | ME | Y |   | Other Service Providers | Case Manager/Care Coordinator |   |
No ID Information.