Basic Information
| Provider Information | |||||||||
| NPI: | 1992344329 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BASALDUA | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | MEGAN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW-CC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 EAST AVE | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042405662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077773399 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 75 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042406031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077954180 | ||||||||
| FaxNumber: | 2077536419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2020 | ||||||||
| LastUpdateDate: | 03/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CAC6933 | ME | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 104100000X | MC20649 | ME | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.