Provider Demographics
NPI:1386773711
Name:CORREIA, SUSAN HASKELL
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:HASKELL
Last Name:CORREIA
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 1024
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04104-1024
Mailing Address - Country:US
Mailing Address - Phone:207-775-1670
Mailing Address - Fax:
Practice Address - Street 1:380 WESTERN AVE STE D
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-1720
Practice Address - Country:US
Practice Address - Phone:207-775-1670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME43351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME5511272OtherAETNA
ME016910OtherANTHEM BLUE CROSS BLUE SH
ME227305000OtherMAGELLAN
ME227305000OtherMAGELLAN