Provider Demographics
NPI:1477618213
Name:THAYER, ELIZABETH N (LCWS)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:N
Last Name:THAYER
Suffix:
Gender:F
Credentials:LCWS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 ATLANTIC PL
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2316
Mailing Address - Country:US
Mailing Address - Phone:207-661-6654
Mailing Address - Fax:207-842-7773
Practice Address - Street 1:3 FUNDY RD
Practice Address - Street 2:
Practice Address - City:FALMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04105-1775
Practice Address - Country:US
Practice Address - Phone:207-956-1775
Practice Address - Fax:207-847-3096
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC119501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEE400172062Medicare PIN
ME000957106Medicare PIN