Provider Demographics
NPI:1891806840
Name:HASKELL, STEPHANIE LEIGH (PHD)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:LEIGH
Last Name:HASKELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:778 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-4109
Mailing Address - Country:US
Mailing Address - Phone:207-474-6115
Mailing Address - Fax:207-474-2382
Practice Address - Street 1:778 FOREST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-4109
Practice Address - Country:US
Practice Address - Phone:207-399-4552
Practice Address - Fax:207-536-0176
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2018-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS588101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME216680000Medicaid
MEMM4172Medicare ID - Type Unspecified
MER28551Medicare UPIN