Provider Demographics
NPI:1720770365
Name:BEHNKE, COREENA ANNE
Entity Type:Individual
Prefix:
First Name:COREENA
Middle Name:ANNE
Last Name:BEHNKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:RAYMOND
Mailing Address - State:ME
Mailing Address - Zip Code:04071-6042
Mailing Address - Country:US
Mailing Address - Phone:207-712-6101
Mailing Address - Fax:
Practice Address - Street 1:1011 FOREST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-3304
Practice Address - Country:US
Practice Address - Phone:207-781-8881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME328550252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency