Provider Demographics
NPI:1245361468
Name:MAGNUSON, ELISE C (PSYD)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:C
Last Name:MAGNUSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 WOODFORD ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-5617
Mailing Address - Country:US
Mailing Address - Phone:207-632-6965
Mailing Address - Fax:207-761-8150
Practice Address - Street 1:251 WOODFORD ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-5617
Practice Address - Country:US
Practice Address - Phone:207-632-6965
Practice Address - Fax:207-761-8150
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC114251041C0700X
MEPS 1242103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical