Provider Demographics
NPI:1114013661
Name:POPENOE, ELLEN J (PHD, MPH)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:J
Last Name:POPENOE
Suffix:
Gender:F
Credentials:PHD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 US ROUTE 1
Mailing Address - Street 2:BUILDING C
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9701
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:1577 CONGRESS ST.
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2169
Practice Address - Country:US
Practice Address - Phone:207-662-1442
Practice Address - Fax:207-775-2467
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MEPS557103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431921399Medicaid
MM5015Medicare ID - Type Unspecified