Provider Demographics
NPI:1194964114
Name:WOLPH-JOHNSON, MAXINE
Entity type:Individual
Prefix:
First Name:MAXINE
Middle Name:
Last Name:WOLPH-JOHNSON
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 288
Mailing Address - Street 2:
Mailing Address - City:ANSON
Mailing Address - State:ME
Mailing Address - Zip Code:04911-0288
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18 COMMON ST
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-6678
Practice Address - Country:US
Practice Address - Phone:207-696-4225
Practice Address - Fax:207-696-4211
Is Sole Proprietor?:No
Enumeration Date:2009-02-14
Last Update Date:2009-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC122101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431821099Medicaid