Provider Demographics
NPI:1437879608
Name:MUKANKUSI, ANNE MARIE
Entity Type:Individual
Prefix:
First Name:ANNE MARIE
Middle Name:
Last Name:MUKANKUSI
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 1:51 ASTER LN APT 8
Mailing Address - Street 2:
Mailing Address - City:CAPE ELIZABETH
Mailing Address - State:ME
Mailing Address - Zip Code:04107-5139
Mailing Address - Country:US
Mailing Address - Phone:301-717-5272
Mailing Address - Fax:
Practice Address - Street 1:500 FOREST AVE STE 6
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-1520
Practice Address - Country:US
Practice Address - Phone:301-717-5272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL6824101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional