Provider Demographics
NPI:1194811398
Name:LITTLE, AGNES E (PSYD)
Entity type:Individual
Prefix:DR
First Name:AGNES
Middle Name:E
Last Name:LITTLE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:LIZA
Other - Middle Name:E
Other - Last Name:LITTLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:899 RIVERSIDE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1070
Mailing Address - Country:US
Mailing Address - Phone:207-871-1200
Mailing Address - Fax:207-871-1232
Practice Address - Street 1:899 RIVERSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-1070
Practice Address - Country:US
Practice Address - Phone:207-871-1200
Practice Address - Fax:207-871-1232
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1140103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical