Provider Demographics
NPI:1376778449
Name:SIMPSON, THERESA A (LCSW)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:SIMPSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:ANNE
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 GANNETT DRIVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106
Mailing Address - Country:US
Mailing Address - Phone:207-523-3649
Mailing Address - Fax:207-874-1483
Practice Address - Street 1:84 MARGINAL WAY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2443
Practice Address - Country:US
Practice Address - Phone:207-774-5816
Practice Address - Fax:207-523-8595
Is Sole Proprietor?:No
Enumeration Date:2009-05-19
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC68421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432087899Medicaid
MEMM879101Medicare PIN
MEE400172112Medicare PIN