Provider Demographics
NPI:1700516143
Name:ANSON, ALISE (LMSW-CC)
Entity Type:Individual
Prefix:
First Name:ALISE
Middle Name:
Last Name:ANSON
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 1:9 LOWELL RD
Mailing Address - Street 2:
Mailing Address - City:GORHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04038-1819
Mailing Address - Country:US
Mailing Address - Phone:845-532-0556
Mailing Address - Fax:
Practice Address - Street 1:55 FODEN RD
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-1717
Practice Address - Country:US
Practice Address - Phone:207-653-5585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC211371041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool