Provider Demographics
NPI:1316130511
Name:DEGRANDPRE, KAREN AMANDA (LMSW-CC)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:AMANDA
Last Name:DEGRANDPRE
Suffix:
Gender:F
Credentials:LMSW-CC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 WALLACE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-6143
Mailing Address - Country:US
Mailing Address - Phone:207-761-0650
Mailing Address - Fax:207-761-8198
Practice Address - Street 1:100 CAMPUS DR
Practice Address - Street 2:UNIT 107
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-9692
Practice Address - Country:US
Practice Address - Phone:207-885-7565
Practice Address - Fax:207-885-7577
Is Sole Proprietor?:No
Enumeration Date:2007-08-21
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC11270104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker