Provider Demographics
NPI:1528539335
Name:MARK G KIEFNER PHD LLC
Entity Type:Organization
Organization Name:MARK G KIEFNER PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:G
Authorized Official - Last Name:KIEFNER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:207-400-2694
Mailing Address - Street 1:98 SHERIDAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2626
Mailing Address - Country:US
Mailing Address - Phone:207-400-2694
Mailing Address - Fax:207-331-3249
Practice Address - Street 1:225 COMMERCIAL ST STE 403
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-6603
Practice Address - Country:US
Practice Address - Phone:207-400-2694
Practice Address - Fax:207-331-3249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty