Basic Information
| Provider Information | |||||||||
| NPI: | 1558347385 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | INGERSON | ||||||||
| FirstName: | SYLVIA | ||||||||
| MiddleName: | IRENE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PMH-N, CNS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEVASSEUR | ||||||||
| OtherFirstName: | SYLVIA | ||||||||
| OtherMiddleName: | IRENE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PMH NP CNS LADC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 213 TITCOMB HILL RD 4B | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049385639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077781862 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 213 TITCOMB HILL RD | ||||||||
| Address2: | UNIT B4 | ||||||||
| City: | FARMINGTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049385639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2072888604 | ||||||||
| FaxNumber: | 2072888602 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 12/09/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | CNP81144 | ME | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | RO14261 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 364SP0809X | RO14261 | ME | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Adult |
ID Information
| ID | Type | State | Issuer | Description | 0NS8053 | 05 | VT | MEDICAID | 2082154 | 01 | VT | CIGNA BEHAVIORAL HEALTH | OTHER | 432710499 | 05 | ME | MEDICAID | 68944BS | 01 | VT | BLUE SHIELD OF VT | OTHER |