Provider Demographics
NPI:1497070155
Name:ALICEA, OLGA (LCSW)
Entity Type:Individual
Prefix:
First Name:OLGA
Middle Name:
Last Name:ALICEA
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 1:180 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2957
Mailing Address - Country:US
Mailing Address - Phone:207-874-2141
Mailing Address - Fax:207-874-2164
Practice Address - Street 1:180 PARK AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2957
Practice Address - Country:US
Practice Address - Phone:207-874-2141
Practice Address - Fax:207-874-2164
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-06
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC130871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432723599Medicaid