Provider Demographics
NPI:1154637338
Name:WHITEFORD, MARA
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:WHITEFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 OCEAN ST
Mailing Address - Street 2:#10 A
Mailing Address - City:S PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2849
Mailing Address - Country:US
Mailing Address - Phone:207-767-1211
Mailing Address - Fax:
Practice Address - Street 1:18 OCEAN ST
Practice Address - Street 2:#10 A
Practice Address - City:S PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2849
Practice Address - Country:US
Practice Address - Phone:207-767-1211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-25
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC126321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME435945799OtherPROVIDER ENROLLMENT