Provider Demographics
NPI:1316287188
Name:USOVA, ELENA
Entity type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:USOVA
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 1:71 ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04070
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 PORTLAND AVE APT 7
Practice Address - Street 2:
Practice Address - City:OLD ORCHARD BEACH
Practice Address - State:ME
Practice Address - Zip Code:04064-1527
Practice Address - Country:US
Practice Address - Phone:207-286-6625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-15
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL4100101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health