Provider Demographics
NPI:1497203772
Name:MCDONALD, LEA (MS)
Entity Type:Individual
Prefix:
First Name:LEA
Middle Name:
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 150
Mailing Address - Street 2:
Mailing Address - City:WESTBROOK
Mailing Address - State:ME
Mailing Address - Zip Code:04098-0150
Mailing Address - Country:US
Mailing Address - Phone:207-879-6165
Mailing Address - Fax:207-879-7466
Practice Address - Street 1:741 WARREN AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-1007
Practice Address - Country:US
Practice Address - Phone:207-879-6165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-15
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1-15-18641103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst