Provider Demographics
NPI:1689302614
Name:WASS, JOHN TAGGART (LMSW-CC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:TAGGART
Last Name:WASS
Suffix:
Gender:M
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 1:65 ROBERTS ST APT 1
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2831
Mailing Address - Country:US
Mailing Address - Phone:207-232-5309
Mailing Address - Fax:
Practice Address - Street 1:535 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-4973
Practice Address - Country:US
Practice Address - Phone:207-232-5309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC212061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical