Basic Information
Provider Information | |||||||||
NPI: | 1841387339 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEAVITT | ||||||||
FirstName: | JAMIE | ||||||||
MiddleName: | B. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SCHNOLL | ||||||||
OtherFirstName: | JAMIE | ||||||||
OtherMiddleName: | B. | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LCSW | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 27A CASEY LN | ||||||||
Address2: |   | ||||||||
City: | KENNEBUNK | ||||||||
State: | ME | ||||||||
PostalCode: | 04043 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2074232369 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 283 ELM ST | ||||||||
Address2: |   | ||||||||
City: | BIDDEFORD | ||||||||
State: | ME | ||||||||
PostalCode: | 040053027 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2072823351 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/06/2006 | ||||||||
LastUpdateDate: | 11/14/2013 | ||||||||
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 | 1041C0700X | LC6886 | ME | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 300800099 | 05 | ME |   | MEDICAID |