Basic Information
Provider Information | |||||||||
NPI: | 1407398928 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | D'SALVA-BOUTON | ||||||||
FirstName: | RUBY | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1093 W MAIN ST | ||||||||
Address2: |   | ||||||||
City: | DOVER FOXCROFT | ||||||||
State: | ME | ||||||||
PostalCode: | 044263717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2075648175 | ||||||||
FaxNumber: | 2076312203 | ||||||||
Practice Location | |||||||||
Address1: | 1093 W MAIN ST | ||||||||
Address2: |   | ||||||||
City: | DOVER FOXCROFT | ||||||||
State: | ME | ||||||||
PostalCode: | 044263717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2075648175 | ||||||||
FaxNumber: | 2075643975 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/15/2016 | ||||||||
LastUpdateDate: | 10/15/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/15/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LC19412 | ME | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | MC16385 | ME | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.