Provider Demographics
NPI:1063570950
Name:BOX, KATHERINE ELIZABETH (LCSW)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ELIZABETH
Last Name:BOX
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:ELIZABETH
Other - Last Name:PEDERSON (MAIDEN NAME)
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1295 ATLANTIC HWY
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04849-3600
Mailing Address - Country:US
Mailing Address - Phone:207-470-7090
Mailing Address - Fax:207-470-7094
Practice Address - Street 1:1295 ATLANTIC HWY.
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:ME
Practice Address - Zip Code:04849-3600
Practice Address - Country:US
Practice Address - Phone:207-470-7090
Practice Address - Fax:207-470-7094
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELSX97811041C0700X
MELC13400104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME104000000Medicaid
ME104000000Medicaid