Provider Demographics
NPI:1639413222
Name:FOSS, ELISHA MARIE (LMSW-CC)
Entity Type:Individual
Prefix:
First Name:ELISHA
Middle Name:MARIE
Last Name:FOSS
Suffix:
Gender:F
Credentials:LMSW-CC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 SUMMER ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-6446
Mailing Address - Country:US
Mailing Address - Phone:207-551-0601
Mailing Address - Fax:
Practice Address - Street 1:40 SUMMER ST
Practice Address - Street 2:SUITE 201
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6446
Practice Address - Country:US
Practice Address - Phone:207-551-0601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC13883101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health