Provider Demographics
NPI:1821484940
Name:MANN, KAISA
Entity type:Individual
Prefix:
First Name:KAISA
Middle Name:
Last Name:MANN
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:PO BOX 8484
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04104-8484
Mailing Address - Country:US
Mailing Address - Phone:207-619-3356
Mailing Address - Fax:207-300-6085
Practice Address - Street 1:30 DANFORTH ST STE 311
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4574
Practice Address - Country:US
Practice Address - Phone:207-619-3356
Practice Address - Fax:207-300-6085
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-15
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC5988101YA0400X
MELC177301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1164484093Medicaid