Provider Demographics
NPI:1063851046
Name:INTEGRATIVE THERAPIES FOR CANCER & CHRONIC DISEASE INC
Entity Type:Organization
Organization Name:INTEGRATIVE THERAPIES FOR CANCER & CHRONIC DISEASE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:TETZLAFF
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:207-699-3838
Mailing Address - Street 1:222 AUBURN ST STE 103
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-6005
Mailing Address - Country:US
Mailing Address - Phone:207-699-3838
Mailing Address - Fax:
Practice Address - Street 1:222 AUBURN ST STE 103
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-6005
Practice Address - Country:US
Practice Address - Phone:207-699-3838
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-23
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MENP548701363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432379199Medicaid
ME432379199Medicaid