Provider Demographics
NPI:1710221890
Name:LAUDERBACK, KRISTINA MARIE (MSS, MLSP, LCSW)
Entity Type:Individual
Prefix:MS
First Name:KRISTINA
Middle Name:MARIE
Last Name:LAUDERBACK
Suffix:
Gender:F
Credentials:MSS, MLSP, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORTER
Mailing Address - State:ME
Mailing Address - Zip Code:04068-3527
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:70 MAIN ST
Practice Address - Street 2:
Practice Address - City:PORTER
Practice Address - State:ME
Practice Address - Zip Code:04068-3527
Practice Address - Country:US
Practice Address - Phone:207-625-8126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC184601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical