Provider Demographics
NPI:1396839213
Name:DONELSON, DEBRA J (LCSW)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:J
Last Name:DONELSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 CLIFF AVE
Mailing Address - Street 2:
Mailing Address - City:CAPE ELIZABETH
Mailing Address - State:ME
Mailing Address - Zip Code:04107-5011
Mailing Address - Country:US
Mailing Address - Phone:207-650-2168
Mailing Address - Fax:
Practice Address - Street 1:222 SAINT JOHN ST
Practice Address - Street 2:SUITE 256
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3041
Practice Address - Country:US
Practice Address - Phone:207-671-6444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC4681104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME328790099Medicaid
MEMM815901Medicare PIN
MEMM8159Medicare PIN