Provider Demographics
NPI:1639300635
Name:RUTHERFORD, L.ANNA (LCPC)
Entity Type:Individual
Prefix:MS
First Name:L.ANNA
Middle Name:
Last Name:RUTHERFORD
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 BAXTER BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-1801
Mailing Address - Country:US
Mailing Address - Phone:603-883-0005
Mailing Address - Fax:
Practice Address - Street 1:11 BAXTER BLVD FL 2
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-1801
Practice Address - Country:US
Practice Address - Phone:036-883-0005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-07
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL3431101YM0800X
MECC4327101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME2121RAVENMedicaid