Basic Information
| Provider Information | |||||||||
| NPI: | 1982047270 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROMANOFF | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S.ED. LADC CCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041061704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077747111 | ||||||||
| FaxNumber: | 2077751985 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041061704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077747111 | ||||||||
| FaxNumber: | 2077751985 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2013 | ||||||||
| LastUpdateDate: | 04/17/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CCS2832 | ME | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | LC2417 | ME | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.