Basic Information
| Provider Information | |||||||||
| NPI: | 1194182444 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROUTH | ||||||||
| FirstName: | COLIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041032737 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 901 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041032737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078711211 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2016 | ||||||||
| LastUpdateDate: | 07/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | MC15799 | ME | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | LC16924 | ME | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.