Provider Demographics
NPI:1417966102
Name:SIMON, SUZANNE (MA)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:SIMON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 MAIETTA PARKWAY
Mailing Address - Street 2:UNIT 7
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106
Mailing Address - Country:US
Mailing Address - Phone:207-799-1749
Mailing Address - Fax:207-773-0472
Practice Address - Street 1:95 EXCHANGE ST
Practice Address - Street 2:NEW ENGLAND FAMILY INSTITUTE, SUITE 100
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101
Practice Address - Country:US
Practice Address - Phone:207-871-1000
Practice Address - Fax:207-773-0472
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC2723101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME048364OtherPROVIDER #-ANTHEM
ME355527OtherPROVIDER #-MHN/TRICARE