Provider Demographics
NPI:1215365853
Name:BAGHESTANI, BRITTA
Entity Type:Individual
Prefix:
First Name:BRITTA
Middle Name:
Last Name:BAGHESTANI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRITTA
Other - Middle Name:
Other - Last Name:KOETTING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPCP-C
Mailing Address - Street 1:280 GANNETT DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-6940
Mailing Address - Country:US
Mailing Address - Phone:207-210-3746
Mailing Address - Fax:
Practice Address - Street 1:280 GANNETT DR
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-6940
Practice Address - Country:US
Practice Address - Phone:207-210-3746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL4194101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional